Organization
LARGO PHYSICIAN GROUP, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
WILLIAM TEDRICK JOHNSON (DIVISION VP/AO)
(615) 372-3375
Entity
Organization
Contact information
Practice address
11373 CORTEZ BLVD STE 408, BROOKSVILLE, FL 34613-5406
(352) 592-7310
Mailing address
2000 HEALTH PARK DR, BRENTWOOD, TN 37027-4525
(615) 373-7600
(866) 346-1426
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000757300
MEDICAID --INDIAN ROCKS LOCATION
FL
01
—
000757301
MEDICAID-WALSINGHAM LOCATION
FL
01
—
000757303
MEDICAID-BARDMOOR LOCATION
FL
01
—
72062
BCBS FL--INDIAN ROCKS
FL
01
—
72062A
BCBS FL-WALSINGHAM
FL
01
—
72062B
BCBS FL--38TH AVE N.
FL
01
—
76062C
BCBS FL-- BARDMOOR
FL
Enumeration date
02/21/2008
Last updated
10/21/2020
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