Healthcare Provider Details

I. General information

NPI: 1174234355
Provider Name (Legal Business Name): TAMPA GENERAL MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2022
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1411 N WEST SHORE BLVD STE 115
TAMPA FL
33607-4564
US

IV. Provider business mailing address

PO BOX 1289
TAMPA FL
33601-1289
US

V. Phone/Fax

Practice location:
  • Phone: 813-844-3541
  • Fax: 813-844-4283
Mailing address:
  • Phone: 813-844-3956
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: PETER TRAVIS RIAD CHANG
Title or Position: VP HEALTHCARE DESIGN
Credential:
Phone: 813-844-3829