Healthcare Provider Details

I. General information

NPI: 1366478109
Provider Name (Legal Business Name): ASANTE-KORANG EDWARDS GIROUD MARTINEZ MCCORMACK & SUH MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 07/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 DR MLKING JR ST NO 400
ST PETERSBURG FL
33705
US

IV. Provider business mailing address

880 6TH ST S 280
ST PETERSBURG FL
33701-4827
US

V. Phone/Fax

Practice location:
  • Phone: 727-767-4200
  • Fax: 727-767-8047
Mailing address:
  • Phone: 727-767-4200
  • Fax: 727-767-8047

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number
License Number State

VIII. Authorized Official

Name: JORGE MCCORMACK
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: MD
Phone: 727-767-4200