Healthcare Provider Details

I. General information

NPI: 1568143725
Provider Name (Legal Business Name): GERIATRIC MEDICAL SPECIALISTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2023
Last Update Date: 07/28/2023
Certification Date: 07/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 CENTRAL AVE FL 4
ST PETERSBURG FL
33701-3566
US

IV. Provider business mailing address

200 CENTRAL AVE FL 4
ST PETERSBURG FL
33701-3566
US

V. Phone/Fax

Practice location:
  • Phone: 317-370-2013
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: TOM HAITHCOAT
Title or Position: PRESIDENT
Credential:
Phone: 317-370-2013