MEDICARE: RMG IVF/ SURGERY 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	261QA0006X	Ambulatory Fertility Facility	1193	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	6F9	OTHER	FL	BCBS NUMBER
2	10D1017148	OTHER	FL	CLIA

General Provider Information

NPI Number	:	1255326302
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RMG IVF/ SURGERY CENTER LLC

Provider Business Mailing Address
First Line	:	5249 E FLETCHER AVE
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33617-1126
Country	:	US
Telephone Number	:	813-989-0120
Fax Number	:	813-989-0268

Provider Business Practice Location Address
First Line	:	5249 E FLETCHER AVE
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33617-1126
Country	:	US
Telephone Number	:	813-989-0120
Fax Number	:	813-989-0268

Authorized Official
Title or Position	:	PRESIDENT
Name	:	SAMUEL TARANTINO JR.
Credential	:	M.D.
Telephone Number	:	813-989-0120

Provider Enumeration Date	:	09/14/2005
Last Update Date	:	01/25/2022

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