=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053853044
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMMUNITY HEALTH SOLUTIONS OF AMERICA PSO, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/08/2016
-----------------------------------------------------
Last Update Date | 11/28/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13600 ICOT BLVD BLDG B
-----------------------------------------------------
City | CLEARWATER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33760-3703
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-290-6321
-----------------------------------------------------
Fax | 888-875-1592
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13600 ICOT BLVD BLDG B
-----------------------------------------------------
City | CLEARWATER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33760-3703
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-290-6321
-----------------------------------------------------
Fax | 888-875-1592
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SECRETARY
-----------------------------------------------------
Name | DALE SCHMIDT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 888-290-6321
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 213EP1101X
-----------------------------------------------------
Taxonomy Name | Primary Podiatric Medicine Podiatrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------