MEDICARE: PARK STREET WOMEN'S CENTER, P.A.

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	ME0069863	FL

General Provider Information

NPI Number	:	1437391513
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PARK STREET WOMEN'S CENTER, P.A.

Provider Business Mailing Address
First Line	:	3801 PARK ST N
Second Line	:	SUITE 4
City	:	ST PETERSBURG
State	:	FL
Zip	:	33709-4078
Country	:	US
Telephone Number	:	727-347-2489
Fax Number	:	727-343-7815

Provider Business Practice Location Address
First Line	:	3801 PARK ST N
Second Line	:	SUITE 4
City	:	ST PETERSBURG
State	:	FL
Zip	:	33709-4078
Country	:	US
Telephone Number	:	727-347-2489
Fax Number	:	727-343-7815

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MARIA M GREGORY
Credential	:	M. D.
Telephone Number	:	727-347-2489

Provider Enumeration Date	:	04/03/2009
Last Update Date	:	04/03/2009

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