Healthcare Provider Details

I. General information

NPI: 1962804393
Provider Name (Legal Business Name): FAD TAMPA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2014
Last Update Date: 10/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2664 CYPRESS RIDGE BLVD SUITE 102B
WESLEY CHAPEL FL
33544-6325
US

IV. Provider business mailing address

2664 CYPRESS RIDGE BLVD SUITE 102B
WESLEY CHAPEL FL
33544-6325
US

V. Phone/Fax

Practice location:
  • Phone: 813-262-2102
  • Fax: 813-737-0096
Mailing address:
  • Phone: 813-262-2102
  • Fax: 813-737-0096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YS0012X
TaxonomySleep Medicine (Otolaryngology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: ARUN RAMABADRAN
Title or Position: CEO
Credential:
Phone: 813-379-3084