MEDICARE: AMY LYNNE BEARISON

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	390200000X	Student in an Organized Health Care Education/Training Program
2	208000000X	Pediatrics Physician	ME155973	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	:	1669935144
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMY LYNNE BEARISON

Provider Business Mailing Address
First Line	:	1919 W SWANN AVE
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33606-2417
Country	:	US
Telephone Number	:	813-254-7079
Fax Number	:	813-443-8164

Provider Business Practice Location Address
First Line	:	1919 W SWANN AVE
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33606-2417
Country	:	US
Telephone Number	:	813-254-7079
Fax Number	:	813-443-8164

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/10/2019
Last Update Date	:	08/19/2022

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