Healthcare Provider Details

I. General information

NPI: 1205872710
Provider Name (Legal Business Name): TAMPA UROLOGY PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 03/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1209 W SWANN AVE
TAMPA FL
33606-2639
US

IV. Provider business mailing address

1209 W SWANN AVE
TAMPA FL
33606-2639
US

V. Phone/Fax

Practice location:
  • Phone: 813-253-3007
  • Fax: 813-253-2098
Mailing address:
  • Phone: 813-253-3007
  • Fax: 813-253-2098

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number05 8026
License Number StateFL

VIII. Authorized Official

Name: DR. MALCOLM ROOT
Title or Position: OWNER PRESIDENT
Credential: MD
Phone: 813-253-3007