MEDICARE: MEDICAL CENTER ON THE GULF 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	207R00000X	Internal Medicine Physician

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	110239219	OTHER		RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
2	K8814	OTHER	GRP #
3	P2746142	OTHER	OXFORD HEALTH INSURANCE
4	244046	OTHER	AVMED
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	410972	OTHER	TUFTS HEALTH PLAN
7	5306646	OTHER	AETNA
8	1627837	OTHER	FIRST HEALTH
9	213422	OTHER	AMERIGROUP
10	3087332	OTHER	CIGNA
11	43705	OTHER	BLUE CROSS BLUE SHIELD
12	0407698	OTHER	UNITED HEALTHCARE
13	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1497720700
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDICAL CENTER ON THE GULF LLC

Provider Business Mailing Address
First Line	:	PO BOX 1921
Second Line	:
City	:	DUNEDIN
State	:	FL
Zip	:	34697-1921
Country	:	US
Telephone Number	:	727-738-0220
Fax Number	:	727-734-7072

Provider Business Practice Location Address
First Line	:	30522 US 19 N STE 109
Second Line	:
City	:	PALM HARBOR
State	:	FL
Zip	:	34684-4436
Country	:	US
Telephone Number	:	727-738-0220
Fax Number	:	727-734-7072

Authorized Official
Title or Position	:	CHAIRMAN
Name	:	ANANDA SOM
Credential	:	MD
Telephone Number	:	727-738-0220

Provider Enumeration Date	:	02/21/2006
Last Update Date	:	07/13/2015

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Practice Location Address:

30522 US 19 N STE 109
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34684-4436

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1831729748 — KERI ALLISON KAVALAR BCBA
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1821624867 — ELIZABETH DIAZ LMHC, NCC
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1245834258 — EMILY MICHAEL PTA
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Directions to “MEDICAL CENTER ON THE GULF LLC ” Practice Location

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