=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639318637
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GERALD A NIEDZWIECKI MD PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/13/2009
-----------------------------------------------------
Last Update Date | 05/29/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2730 N MCMULLEN BOOTH RD SUITE 203
-----------------------------------------------------
City | CLEARWATER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33761-3302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-286-8929
-----------------------------------------------------
Fax | 727-286-8933
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2730 N MCMULLEN BOOTH RD SUITE 100
-----------------------------------------------------
City | CLEARWATER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33761-3302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-791-7300
-----------------------------------------------------
Fax | 727-723-9010
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/SHAREHOLDER
-----------------------------------------------------
Name | DR. GERALD ANTHONY NIEDZWIECKI
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 727-791-7300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085N0700X
-----------------------------------------------------
Taxonomy Name | Neuroradiology Physician
-----------------------------------------------------
License Number | ME81474
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | ME0070649
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | ME81474
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 2085U0001X
-----------------------------------------------------
Taxonomy Name | Diagnostic Ultrasound Physician
-----------------------------------------------------
License Number | ME0070649
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PAT9104325
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 2085R0204X
-----------------------------------------------------
Taxonomy Name | Vascular & Interventional Radiology Physician
-----------------------------------------------------
License Number | ME0070649
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------