MEDICARE: ALL KIDS CLINIC

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	261QM2500X	Medical Specialty Clinic/Center	ME56110	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1306058144
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALL KIDS CLINIC

Provider Business Mailing Address
First Line	:	PO BOX 15876
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33684-5876
Country	:	US
Telephone Number	:	813-849-5437
Fax Number	:	813-849-2624

Provider Business Practice Location Address
First Line	:	1922 W. MARTIN LUTHER KING JR. BLVD
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33607-6510
Country	:	US
Telephone Number	:	813-849-5437
Fax Number	:	813-849-2624

Authorized Official
Title or Position	:	PRESIDENT
Name	:	AGUSTIN ALFONSO MARTIN
Credential	:	M.D.
Telephone Number	:	813-849-5437

Provider Enumeration Date	:	05/04/2007
Last Update Date	:	03/21/2014

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