Healthcare Provider Details

I. General information

NPI: 1447901418
Provider Name (Legal Business Name): JEREMY MICHAEL OBRADOVICH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2022
Last Update Date: 01/12/2022
Certification Date: 01/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3217 S MACDILL AVE
TAMPA FL
33629-1719
US

IV. Provider business mailing address

1321 MURFREESBORO PIKE STE 702
NASHVILLE TN
37217-2679
US

V. Phone/Fax

Practice location:
  • Phone: 813-284-7941
  • Fax: 615-815-1946
Mailing address:
  • Phone: 615-361-4000
  • Fax: 615-815-1946

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: