Provider Demographics
NPI:1902810963
Name:PHYSICAL MEDICINE CENTER
Entity Type:Organization
Organization Name:PHYSICAL MEDICINE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CLINIC DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:CARL
Authorized Official - Last Name:LUPO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:813-978-0020
Mailing Address - Street 1:14522 UNIVERSITY POINT PL
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33613-5425
Mailing Address - Country:US
Mailing Address - Phone:813-978-0020
Mailing Address - Fax:813-972-9024
Practice Address - Street 1:14522 UNIVERSITY POINT PL
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-5425
Practice Address - Country:US
Practice Address - Phone:813-978-0020
Practice Address - Fax:813-972-9024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2010-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL22031OtherBCBS
FLPT9405OtherLICENSE#
FLCH5346OtherLICENSE#
FL21592OtherBCBS
FLCH9181OtherLICENSE NUMBER
FLME23061OtherLICENSE#
FLCH8350OtherLICENSE
FL12043OtherBCBS
FLCH8937OtherLICENSE#
FLU67258Medicare UPIN
FLD61599Medicare UPIN
FL22031Medicare ID - Type Unspecified
FL12043AMedicare ID - Type Unspecified
FL22031OtherBCBS
FLCH8350OtherLICENSE
FLT84275Medicare UPIN