Provider Demographics
NPI:1174663694
Name:PREMIER OB/GYN
Entity type:Organization
Organization Name:PREMIER OB/GYN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VICKIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-876-6000
Mailing Address - Street 1:2727 W DR MLK JR BLVD
Mailing Address - Street 2:SUITE 630
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607
Mailing Address - Country:US
Mailing Address - Phone:813-876-6000
Mailing Address - Fax:813-876-0590
Practice Address - Street 1:2727 W DR MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:SUITE 630
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6383
Practice Address - Country:US
Practice Address - Phone:813-876-6000
Practice Address - Fax:813-876-0590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 43544207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0615498Medicaid
FL0615498Medicaid
D62204Medicare UPIN