Healthcare Provider Details

I. General information

NPI: 1790774701
Provider Name (Legal Business Name): JULIE A. KISH M. D., FACP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2005
Last Update Date: 02/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12902 USF MAGNOLIA DR
TAMPA FL
33612-9416
US

IV. Provider business mailing address

12902 MAGNOLIA DRIVE MCC-SA H. LEE MOFFITT CANCER CENTER & RESEARCH INSTITUTE
TAMPA FL
33612-9416
US

V. Phone/Fax

Practice location:
  • Phone: 813-745-4673
  • Fax:
Mailing address:
  • Phone: 813-745-3822
  • Fax: 813-745-1908

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License NumberME0067902
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License NumberG6191
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: