Individual
PREM FORT
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
501 6TH AVE S, ST PETERSBURG, FL 33701-4634
(727) 767-4313
(727) 767-4391
Mailing address
501 6TH AVE S, ST PETERSBURG, FL 33701-4634
(727) 767-4313
(727) 767-4391
Taxonomy
Speciality
Code
Description
License number
State
2080N0001X
Neonatal-Perinatal Medicine Physician
Primary
ME123447
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
014799700
—
FL
Enumeration date
05/01/2008
Last updated
06/24/2016
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