| Waters Edge Medical Clinic Tampa Llc | |
|
1700 66th St N Ste 304 St Petersburg FL 33710-5500 | |
| (727) 550-0855 | |
| Not Available |
| Full Name | Waters Edge Medical Clinic Tampa Llc |
|---|---|
| Speciality | Clinic/Center |
| Location | 1700 66th St N Ste 304, St Petersburg, Florida |
| Authorized Official Name and Position | Vida Vodopalas-puodziunas (OWNER) |
| Authorized Official Contact | 8156039683 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Waters Edge Medical Clinic Tampa Llc 1700 66th St N Ste 304 St Petersburg FL 33710-5500 Ph: (727) 550-0855 | Waters Edge Medical Clinic Tampa Llc 1700 66th St N Ste 304 St Petersburg FL 33710-5500 Ph: (727) 550-0855 |
| NPI Number | 1265054803 |
|---|---|
| Provider Enumeration Date | 05/16/2020 |
| Last Update Date | 08/23/2023 |
| Medicare PECOS PAC ID | 0749691079 |
|---|---|
| Medicare Enrollment ID | O20201118000070 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1265054803 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QM1300X | Clinic/center - Multi-specialty | (* (Not Available)) | Primary |
| 261QP2300X | Clinic/center - Primary Care | (* (Not Available)) | Secondary |
| Provider Name | Fred E Clark |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1609022086 PECOS PAC ID: 5092851212 Enrollment ID: I20091001000480 |
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