Healthcare Provider Details

I. General information

NPI: 1750335329
Provider Name (Legal Business Name): AXIOM MEDICAL CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9507 ANDERSON RD
TAMPA FL
33634-1252
US

IV. Provider business mailing address

7177 CRIMSON RIDGE DR SUITE 14
ROCKFORD IL
61107-6208
US

V. Phone/Fax

Practice location:
  • Phone: 813-319-1330
  • Fax: 813-319-1340
Mailing address:
  • Phone: 815-227-9900
  • Fax: 815-227-9805

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME 93347
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH 8788
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT20245
License Number StateFL

VIII. Authorized Official

Name: WENDY NEWMAN
Title or Position: COMPTROLLER
Credential:
Phone: 815-227-9900