Healthcare Provider Details

I. General information

NPI: 1487963864
Provider Name (Legal Business Name): SPECIALIST DOCTORS GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2010
Last Update Date: 03/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 N ALEXANDER ST
PLANT CITY FL
33563-4302
US

IV. Provider business mailing address

P.O. BOX 770
LITHIA FL
33547-0570
US

V. Phone/Fax

Practice location:
  • Phone: 813-752-7222
  • Fax: 813-752-7255
Mailing address:
  • Phone: 813-719-3525
  • Fax: 813-719-3175

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number StateFL

VIII. Authorized Official

Name: MR. MICHAEL SALVATO
Title or Position: MEDICAL DIRECTOR
Credential:
Phone: 813-752-7222