Healthcare Provider Details

I. General information

NPI: 1265535371
Provider Name (Legal Business Name): COMPREHENSIVE COLORECTAL CARE PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 07/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4809 N ARMENIA AVE SUITE 220
TAMPA FL
33603-1447
US

IV. Provider business mailing address

PO BOX 550748
JACKSONVILLE FL
32255-0748
US

V. Phone/Fax

Practice location:
  • Phone: 813-875-2600
  • Fax: 813-575-2626
Mailing address:
  • Phone: 803-808-8070
  • Fax: 803-808-8074

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. ROBERT JAMES THEOBALD III
Title or Position: PHYSICIAN
Credential: DO
Phone: 813-875-2600