Healthcare Provider Details

I. General information

NPI: 1720400054
Provider Name (Legal Business Name): PINELLAS NEUROINTERVENTIONAL CONSULTANTS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2014
Last Update Date: 03/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 6TH STREET SOUTH
ST PETERSBURG FL
33701-4814
US

IV. Provider business mailing address

PO BOX 23057
TAMPA FL
33623-3057
US

V. Phone/Fax

Practice location:
  • Phone: 727-823-1234
  • Fax: 813-985-8006
Mailing address:
  • Phone: 813-899-6220
  • Fax: 813-985-8006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. ELLIS B. NORSOPH
Title or Position: PRESIDENT/CEO
Credential: MD
Phone: 813-899-6220