=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306957899
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TAMPA BAY NEPHROLOGY ASSOCIATES P L
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2006
-----------------------------------------------------
Last Update Date | 12/27/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4912 N ARMENIA AVE
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33603-1402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-353-8775
-----------------------------------------------------
Fax | 813-353-3956
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4912 N ARMENIA AVE
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33603-1402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-353-8775
-----------------------------------------------------
Fax | 813-353-3956
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AUTHORIZED MANAGER
-----------------------------------------------------
Name | POLLY A. BITTLE
-----------------------------------------------------
Credential | APRN
-----------------------------------------------------
Telephone | 813-353-8775
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RN0300X
-----------------------------------------------------
Taxonomy Name | Nephrology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------