=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548782592
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TM MEDICAL ASSOCIATES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/12/2017
-----------------------------------------------------
Last Update Date | 07/12/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 131 N MOON AVE STE 3&4
-----------------------------------------------------
City | BRANDON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33510-4418
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-315-9898
-----------------------------------------------------
Fax | 813-438-5967
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11217 LONGBROOKE DR
-----------------------------------------------------
City | RIVERVIEW
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33579-7079
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-362-6816
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | NURSE PRACTITIONER
-----------------------------------------------------
Name | TIMOTHY DAVID MORRILL
-----------------------------------------------------
Credential | ARNP, CAP
-----------------------------------------------------
Telephone | 813-362-6816
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | ARNP9343749
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------