| Entity Name: | CROSS CREEK MEDICAL,PA |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Active |
| Date Filed: | 30 May 2002 (23 years ago) |
| Document Number: | P02000060008 |
| FEI/EIN Number | 141852106 |
| Address: | 1381 CROSS CREEK CIRCLE, #A, TALLAHASSEE, FL, 32301 |
| Mail Address: | 1381 CROSS CREEK CIRCLE, #A, TALLAHASSEE, FL, 32301 |
| ZIP code: | 32301 |
| County: | Leon |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1447438486 | 2008-02-01 | 2011-10-05 | 1381A CROSS CREEK CIR, TALLAHASSEE, FL, 323013729, US | 1381 CROSS CREEK CIR, SUITE A, TALLAHASSEE, FL, 323013723, US | |||||||||||||||||||||||||||||||||||||||
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| Phone | +1 850-877-6393 |
| Fax | 8508776813 |
| Fax | 8508776393 |
Authorized person
| Name | DR. WAYNE A SAMPSON |
| Role | MEDICAL DIRECTOR |
| Phone | 8508776393 |
Taxonomy
| Taxonomy Code | 207R00000X - Internal Medicine Physician |
| License Number | 0071014FLME |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 250984900 |
| State | FL |
| Issuer | RAILROAD MEDICARE |
| Number | DF9814 |
| State | FL |
| Issuer | MEDICAID |
| Number | 003457000 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| SAMPSON WAYNE ADr. | Agent | 1605 GROVELAND HILLS DR., TALLAHASSEE, FL, 32317 |
| Name | Role | Address |
|---|---|---|
| SAMPSON WAYNE A | President | 1381 A CROSS CREEK CIRCLE, TALLAHASSEE, FL, 32301 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| REGISTERED AGENT NAME CHANGED | 2020-04-24 | SAMPSON, WAYNE ANTHONY, Dr. | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-03-06 |
| ANNUAL REPORT | 2023-03-21 |
| ANNUAL REPORT | 2022-03-10 |
| ANNUAL REPORT | 2021-04-07 |
| ANNUAL REPORT | 2020-04-24 |
| ANNUAL REPORT | 2019-02-12 |
| ANNUAL REPORT | 2018-01-12 |
| ANNUAL REPORT | 2017-01-08 |
| ANNUAL REPORT | 2016-03-01 |
| ANNUAL REPORT | 2015-01-12 |
| Loan Number | Loan Funded Date | SBA Origination Office Code | Loan Delivery Method | Borrower Street Address | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| 8813187300 | 2020-05-01 | 0491 | PPP | 1381 CROSS CREEK CIR, TALLAHASSEE, FL, 32301-3729 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Date of last update: 02 Feb 2025
Sources: Florida Department of State
