Healthcare Provider Details

I. General information

NPI: 1235101833
Provider Name (Legal Business Name): CMS ST PETERSBURG
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3251 3RD AVE N
ST PETERSBURGH FL
33713
US

IV. Provider business mailing address

3251 3RD AVE N
ST PETERSBURGH FL
33713
US

V. Phone/Fax

Practice location:
  • Phone: 727-893-2775
  • Fax: 727-893-1101
Mailing address:
  • Phone: 727-893-2775
  • Fax: 727-893-1101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number StateFL

VIII. Authorized Official

Name: MRS. PATRICIA B KOPP
Title or Position: PROGRAM ADMINISTRATOR
Credential:
Phone: 813-396-9798