Provider Demographics
NPI:1043441546
Name:VERIMED HEALTH GROUP PINELLAS PARK, LLC
Entity type:Organization
Organization Name:VERIMED HEALTH GROUP PINELLAS PARK, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JULISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:ORTIZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-577-0285
Mailing Address - Street 1:12450 ROOSEVELT BLVD N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33716-1902
Mailing Address - Country:US
Mailing Address - Phone:727-577-0285
Mailing Address - Fax:727-577-3870
Practice Address - Street 1:12450 ROOSEVELT BLVD N STE 308
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33716-1902
Practice Address - Country:US
Practice Address - Phone:727-577-0285
Practice Address - Fax:727-577-3870
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-31
Last Update Date:2023-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS8908207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDN977AMedicare PIN