| Entity Name: | INFECTIOUS DISEASE CONSULTANTS OF ST. PETERSBURG, P.A. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Active |
| Date Filed: | 02 Jan 2001 (24 years ago) |
| Document Number: | P01000000330 |
| FEI/EIN Number | 593691006 |
| Address: | 4604 29TH ST E, PALMETTO, FL, 34221-9793, US |
| Mail Address: | 4604 29TH ST E, PALMETTO, FL, 34221-9793, US |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1982637195 | 2006-07-09 | 2014-01-24 | 4604 29TH ST E, PALMETTO, FL, 342219793, US | 4604 29TH ST E, PALMETTO, FL, 342219793, US | |||||||||||||||||||||||||||||||||||
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| Phone | +1 941-845-4572 |
| Fax | 9418454572 |
Authorized person
| Name | DR. CLINTON DOUGLAS HOLDER |
| Role | OWNER |
| Phone | 9418454572 |
Taxonomy
| Taxonomy Code | 207RI0200X - Infectious Disease Physician |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | GHI |
| Number | 5600211 |
| Issuer | BLUE CROSS/BLUE SHIELD FL |
| Number | 34252 |
| State | FL |
| Issuer | RAILROAD MEDICARE |
| Number | CB6866 |
| Issuer | MEDICAID |
| Number | 263649200 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| O'CONNOR PATRICK M | Agent | O'CONNOR LAW FIRM, Clearwater, FL, 33764 |
| Name | Role | Address |
|---|---|---|
| HOLDER CLINTON D | Director | 4604 29th ST E, Palmetto, FL, 34221 |
Date of last update: 01 Jan 2025
Sources: Florida Department of State
