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General NPI Number Information
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NPI Number | 1538421664
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Entity Type | Organization
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Legal Business Name | PREMIUM HEALTH SERVICES OF TAMPA BAY
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Dates
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Enumeration Date | 06/14/2012
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Last Update Date | 06/25/2019
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Provider Practice Location Address
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Address Line | 4018 HIGHVIEW RD.
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City | SEFFNER
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State | FL
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Zip | 33584-4923
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Country | US
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Telephone | 813-651-4100
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Fax | 813-651-4111
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Provider Business Mailing Address
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Address Line | 11752 E MLK BLVD
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City | SEFFNER
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State | FL
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Zip | 33584-4923
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. KHAWAJA RAHMAN
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Credential | MD
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Telephone | 813-641-0068
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QU0200X
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Taxonomy Name | Urgent Care Clinic/Center
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License Number | ME79013
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License Number State | FL
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