Healthcare Provider Details

I. General information

NPI: 1396489225
Provider Name (Legal Business Name): TAMPA GENERAL MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2022
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1202 S CHURCH AVE STE A
TAMPA FL
33629-5017
US

IV. Provider business mailing address

PO BOX 1289
TAMPA FL
33601-1289
US

V. Phone/Fax

Practice location:
  • Phone: 813-821-8095
  • Fax: 813-821-8309
Mailing address:
  • Phone: 813-844-3956
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State

VIII. Authorized Official

Name: PETER TRAVIS RIAD CHANG
Title or Position: VP CARE TRANSITIONS
Credential:
Phone: 813-844-3956