MEDICARE: CARILLON SPORTS AND FAMILY MEDICINE PA

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	207QS0010X	Sports Medicine (Family Medicine) Physician	ME80751	FL

General Provider Information

NPI Number	:	1275730970
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CARILLON SPORTS AND FAMILY MEDICINE PA

Provider Business Mailing Address
First Line	:	12225 28TH ST N
Second Line	:	SUITE B
City	:	ST PETERSBURG
State	:	FL
Zip	:	33716-1860
Country	:	US
Telephone Number	:	727-561-4303
Fax Number	:	727-561-9299

Provider Business Practice Location Address
First Line	:	12225 28TH ST N
Second Line	:	SUITE B
City	:	ST PETERSBURG
State	:	FL
Zip	:	33716-1860
Country	:	US
Telephone Number	:	727-561-4303
Fax Number	:	727-561-9299

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ADAM A BRUNSON
Credential	:	MD
Telephone Number	:	727-561-4303

Provider Enumeration Date	:	06/27/2007
Last Update Date	:	05/12/2011

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