Healthcare Provider Details

I. General information

NPI: 1164912754
Provider Name (Legal Business Name): SUPERIOR PHYSICIAN GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2018
Last Update Date: 05/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10730 N 56TH ST STE 209
TEMPLE TERRACE FL
33617
US

IV. Provider business mailing address

10730 N 56TH ST STE 209
TEMPLE TERRACE FL
33617-3611
US

V. Phone/Fax

Practice location:
  • Phone: 813-365-5680
  • Fax:
Mailing address:
  • Phone: 813-365-5680
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. RENII MODISETTE
Title or Position: OPERATIONS MANAGER
Credential:
Phone: 813-365-5680