MEDICARE: NODAL MEDICAL CENTER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician	ACN693	FL

General Provider Information

NPI Number	:	1114457272
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NODAL MEDICAL CENTER LLC

Provider Business Mailing Address
First Line	:	2123 W DR MARTIN LUTHER KING JR BLVD STE 101
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33607-6545
Country	:	US
Telephone Number	:	813-488-4801
Fax Number	:	813-405-4506

Provider Business Practice Location Address
First Line	:	2123 W DR MARTIN LUTHER KING JR BLVD STE 101
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33607-6545
Country	:	US
Telephone Number	:	813-488-4801
Fax Number	:	813-405-4506

Authorized Official
Title or Position	:	MEDICAL DOCTOR
Name	:	OSVANNY NODAL
Credential	:	MD
Telephone Number	:	813-488-4801

Provider Enumeration Date	:	06/12/2017
Last Update Date	:	06/20/2019

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