Healthcare Provider Details

I. General information

NPI: 1164010187
Provider Name (Legal Business Name): MINIMALLY INVASIVE SURGICAL AFFILIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2021
Last Update Date: 01/05/2021
Certification Date: 01/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2715 N MACDILL AVE
TAMPA FL
33607-2205
US

IV. Provider business mailing address

PO BOX 4706
TAMPA FL
33677-4706
US

V. Phone/Fax

Practice location:
  • Phone: 813-280-0202
  • Fax: 813-280-0203
Mailing address:
  • Phone: 813-280-0202
  • Fax: 813-280-0203

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TALAL HAMDAN
Title or Position: OWNER
Credential: MD
Phone: 813-280-0202