Healthcare Provider Details

I. General information

NPI: 1710260336
Provider Name (Legal Business Name): ST PETERSBURG MEDICAL CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2011
Last Update Date: 05/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

335 31ST SOUTH
ST. PETERSBURG FL
33712-1419
US

IV. Provider business mailing address

335 31ST SOUTH
ST. PETERSBURG FL
33712-1419
US

V. Phone/Fax

Practice location:
  • Phone: 727-289-7139
  • Fax: 727-289-7140
Mailing address:
  • Phone: 727-289-7139
  • Fax: 727-289-7140

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberME92656
License Number StateFL

VIII. Authorized Official

Name: DR. NASSER RAZACK
Title or Position: PRESIDENT
Credential: MD
Phone: 727-289-7139