Healthcare Provider Details

I. General information

NPI: 1427394303
Provider Name (Legal Business Name): CAPITAL MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2012
Last Update Date: 12/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5985 49TH ST N
ST PETERSBURG FL
33709-2111
US

IV. Provider business mailing address

PO BOX 3377
PINELLAS PARK FL
33780-3377
US

V. Phone/Fax

Practice location:
  • Phone: 727-408-3232
  • Fax: 727-527-3715
Mailing address:
  • Phone: 727-408-3232
  • Fax: 727-527-3715

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: PHYLLIS FRIEDRICH
Title or Position: VP OPERATIONS AND BUS DEVELOPMENT
Credential:
Phone: 727-408-3232