Organization
LIVEACTIVE MULTISPECIALTY PHYSICIAN GROUP TAMPA LLC
Active
Other names
LiveActive Multispecialty Physician Group Tampa
Organization subpart
No
Provider details
NPI number
Authorized official
SHANE BRETHOWR (CEO/AUTHORIZED OFFICIAL)
(913) 549-3884
Entity
Organization
Contact information
Practice address
12440 CORTEZ BLVD, BROOKSVILLE, FL 34613-2628
(913) 549-3884
Mailing address
PO BOX 1269, BELLEVUE, NE 68005-1269
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
—
—
208M00000X
Hospitalist Physician
Primary
—
—
Other
Enumeration date
01/16/2024
Last updated
09/14/2024
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