=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306138730
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BAYCARE HEALTH SYSTEM AGENT FOR TRUSTEES OF MEASE HOSPITAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2011
-----------------------------------------------------
Last Update Date | 05/03/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3251 N MCMULLEN BOOTH RD
-----------------------------------------------------
City | CLEARWATER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33761-2022
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-725-6151
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 930 GULF VIEW BLVD
-----------------------------------------------------
City | DUNEDIN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34698-2609
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CERTIFIED ATHLETIC TRAINER
-----------------------------------------------------
Name | KELLY WEBB
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 727-725-6151
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 282N00000X
-----------------------------------------------------
Taxonomy Name | General Acute Care Hospital
-----------------------------------------------------
License Number | AL363
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------