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General NPI Number Information
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NPI Number | 1588834964
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Entity Type | Organization
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Legal Business Name | COUNTRYSIDE NEUROLOGY INC
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Dates
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Enumeration Date | 03/03/2008
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Last Update Date | 03/03/2008
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Provider Practice Location Address
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Address Line | 2349 SUNSET POINT RD STE 403
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City | CLEARWATER
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State | FL
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Zip | 33765-1439
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Country | US
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Telephone | 727-712-1567
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Fax |
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Provider Business Mailing Address
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Address Line | 2349 SUNSET PT RD SUITE 403
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City | CLEARWATER
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State | FL
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Zip | 34682
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Country | US
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Telephone | 727-712-1567
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | ARDESHIR KHADEMI-KEMANSHAHI
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Credential | MD
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Telephone | 727-712-1567
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084N0400X
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Taxonomy Name | Neurology Physician
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License Number | ME80114
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License Number State | FL
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