| Entity Name: | BLUESTONE PHYSICIAN SERVICES SOUTHEAST, LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Active |
| Date Filed: | 30 Mar 2015 (10 years ago) |
| Last Event: | LC NAME CHANGE |
| Event Date Filed: | 10 Aug 2020 (4 years ago) |
| Document Number: | L15000066178 |
| FEI/EIN Number | 59-3568197 |
| Mail Address: | 10150 Highland Manor Drive, TAMPA, FL, 33610, US |
| Address: | 10150 HIGHLAND MANOR DRIVE, TAMPA, FL, 33610, US |
| ZIP code: | 33610 |
| County: | Hillsborough |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1346212370 | 2006-02-03 | 2024-02-07 | 10150 HIGHLAND MANOR DR STE 205, TAMPA, FL, 336109727, US | 10150 HIGHLAND MANOR DR STE 205, TAMPA, FL, 336109727, US | |||||||||||||||||||||||||||||||||
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| Phone | +1 813-259-1013 |
| Fax | 8132540396 |
Authorized person
| Name | DIANA BERNARD I |
| Role | OFFICE MANAGER |
| Phone | 8132591013 |
Taxonomy
| Taxonomy Code | 207Q00000X - Family Medicine Physician |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 015006200 |
| State | FL |
| Issuer | BC/BS |
| Number | 34388 |
| State | FL |
| Issuer | RAILROAD MEDICARE |
| Number | CK5239 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| STIVLAND TODD | Agent | 10150 Highland Manor Drive, TAMPA, FL, 33610 |
| Name | Role | Address |
|---|---|---|
| STIVLAND TODD | Chief Executive Officer | 270 North Main Street, Stillwater, MN, 55082 |
| Name | Role | Address |
|---|---|---|
| Nelsen David | Chief Financial Officer | 270 North Main Street, Stillwater, MN, 55082 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| REGISTERED AGENT NAME CHANGED | 2022-01-17 | STIVLAND, TODD | No data |
| LC NAME CHANGE | 2020-08-10 | BLUESTONE PHYSICIAN SERVICES SOUTHEAST, LLC | No data |
| LC STMNT CORR | 2020-01-27 | No data | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2019-04-19 | 10150 Highland Manor Drive, TAMPA, FL 33610 | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2019-04-19 | 10150 HIGHLAND MANOR DRIVE, TAMPA, FL 33610 | No data |
| CHANGE OF MAILING ADDRESS | 2019-04-19 | 10150 HIGHLAND MANOR DRIVE, TAMPA, FL 33610 | No data |
| LC AMENDMENT | 2015-05-15 | No data | No data |
| MERGER | 2015-05-11 | No data | CORPORATION WAS A MERGER RESULT. TOTAL NUMBER OF QUALIFIED CORPORATION(S) INVOLVED WAS 1. MERGER NUMBER 100000151571 |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-02-12 |
| ANNUAL REPORT | 2023-02-11 |
| ANNUAL REPORT | 2022-01-17 |
| ANNUAL REPORT | 2021-01-22 |
| LC Name Change | 2020-08-10 |
| ANNUAL REPORT | 2020-02-05 |
| CORLCSTCOR | 2020-01-27 |
| ANNUAL REPORT | 2019-04-19 |
| ANNUAL REPORT | 2018-03-06 |
| AMENDED ANNUAL REPORT | 2017-04-14 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
