Healthcare Provider Details

I. General information

NPI: 1437609807
Provider Name (Legal Business Name): ST. PETERSBURG MEDICAL CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2016
Last Update Date: 10/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 EAST AVE
LOCKPORT NY
14094-3812
US

IV. Provider business mailing address

2001 16TH ST N ATTN:PAUL C JENSEN
ST PETERSBURG FL
33704-3921
US

V. Phone/Fax

Practice location:
  • Phone: 716-438-3546
  • Fax:
Mailing address:
  • Phone: 716-438-3546
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number202334
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number202334
License Number StateNY

VIII. Authorized Official

Name: DR. MOHAMED KHALAF
Title or Position: MANAGER
Credential: MD
Phone: 716-438-3546