About Moffitt Cancer CenterMoffittis dedicated to one lifesaving mission: to contribute to the prevention and cure of cancer. Apply for the Job in Senior Director Patient Access at Carrollwood, FL. If you are eligible for a virtual appointment, our scheduling team will discuss this option further with you. REFERRING PHYSICIANS Providers and medical staff can refer patients by submitting our online referral form. Marc Perkins-Carrillo is responsible for the development, implementation, and adoption of clinical IT solutions to facilitate patient care. Support WUSF now by giving monthly, or make a one-time donation online. The Agile services team also provides Scrum Master support and enablement to several cross-functional teams across CDH. The open exchange of ideas and Moffitts culture of innovative collaboration have made it a global leader in developing breakthrough research to save lives through the prevention, treatment and cure of cancer. DeNicola, who joined Moffitt in 2016, also serves as the interim chair of the Department of Metabolism and Physiology. Sissy Marler-Schilling, MHA - Chief Applications Systems Officer, IT Administration. A secure website for patients to access their medical care at Moffitt. Patient Food Service. We will continue to be careful stewards of the public money entrusted to us for cancer research. For more information on how were protecting our new and existing patients, visit our COVID-19 Info Hub. Moffitt Cancer Center is committed to the health and safety of our patients and their families. He is seeking damages on each count to recover lost wages, loss of ability to earn a living, mental anguish, personal humiliation, damage to reputation and damage to continue or develop business relationships. Randa Perkins, MD, MBA, FAMIA - Chief Medical Information Officer, Senior Director of Clinical Informatics, Assistant Member, Department of Internal Medicine, Assistant Professor of Medicine, USF College of Medicine. This team is responsible for the implementation and adoption of Moffitt cloud-based Cancer Analytics Platform, Data Governance and realizing enterprise value through Data Science products and applications. By, Port Tampa Bay is seeing an increase in both cargo trade and cruise passengers, SpaceX, NASA try once again to launch a multinational crew from the Kennedy Space Center, Eli Lilly cuts the price of insulin, capping drug at $35 per month out-of-pocket, A proposal would expand Florida's controversial education law on teaching about sexual orientation, Here are 8 big revelations from the Alex Murdaugh murder trial, 'Whoever holds power, it's going to corrupt them,' says 'Tr' director Todd Field, Greek prime minister says 'human error' caused a train collision that left 43 dead, Rebecca Makkai's smart, prep school murder novel is self-aware about the 'ick' factor, House Continues To Probe Chinese Meddling At Moffitt, Other Institutions, Moffitt Investigation Faults Doctors For Not Disclosing China Relationships, Oliva Forms Select Committee After Moffitt Resignations, Speaker Oliva Says House Will Investigate Moffitts China Connection, Moffitt Cancer Center President, Director Resign Amid China Investigation. Moffitt Cancer Center Employee Directory. Santosh Mohan is responsible for launching the Digital organization within Moffitts Center for Digital Health. I interviewed at Moffitt Cancer Center (Tampa, FL) in Nov 2022. [36], Moffitt at International Plaza is a 50,000-square-foot full service outpatient facility near Tampa International Airport. Patient Appointment Center Hours: 7 a.m. to 7 p.m. Monday - Friday; 8 a.m. to noon Saturday, Executive Vice President, Center Director, Executive Vice President, General Counsel, Executive Vice President, Physician-in-Chief, Executive Vice President, Chief Philanthropy Officer and Foundation President, Executive Vice President, Chief Operating Officer, Hospital President, CPA, MBA, Executive Vice President/Chief Financial & Administrative Officer, Vice President, Ambulatory and Virtual Care Operations, Vice President, Human Resources Operations, Vice President, Planning, Design and Construction, Vice President of Patient Care Services and Chief Nursing Officer, Vice President, Chief Diversity, Equity, and Inclusion Officer, Chair Emeritus, Department of Radiation Oncology; Senior Physician Executive, Vice President, Quality/Chief Medical Officer, Vice President, Clinical Trials and Operations Excellence, Vice President, Chief Information Officer, Vice President and Chief Innovation Officer, Senior Vice President and Chief Digital Officer, Vice President and Chief Data Officer; Associate Center Director of Data Science, Vice President, Research Administration;Associate Center Director, Administration, Vice President, Facilities & Support Services, Radiology Diagnostic Imaging and Interventional Radiology, Diagnostic Imaging and Interventional Radiology, Moffitt Malignant Hematology & Cellular Therapy at Memorial Healthcare System, Cancer Pharmacokinetics and Pharmacodynamics, Participant Research, Interventions, and Measurement Core (PRISM), Office of Undergraduate and Visiting Scholar Affairs, Community Outreach, Engagement, and Equity, Ambulatory Care Oncology Nurse Residency Program, International Relationships and Disclosures, Team Member Engagement Networks/Faculty Employee Networks, DeBartolo Family Personalized Medicine Institute, Pinellas Residents Receive Moffitt Radiation Services Closer to Home, Moffitt Cancer Center, AdventHealth Join Forces to Expand Cancer Care, National Comprehensive Cancer Network (NCCN), Board of Directors, Committee Members Only. In 2017, the NCI renewed Moffitt's Cancer Center Support Grant for another five years. The alliance brings the renowned cancer center's access to research, clinical trials, and comprehensive treatment to leukemia, lymphoma and multiple myeloma patients. In 1990, the acquisition of the Research Center building across from the Cancer Center enhanced the recruitment of scientists, clinicians, and support staff, and expanded Moffitt's vision beyond the original structure. As the organization's designated HIPAA Security Officer, his team coordinates with applications and system administrators to ensure the required technical controls are implemented to ensure the confidentiality, integrity and availability of the organizations mission and business-critical data. Dr. Stapps interests include applications of artificial intelligence and machine learning in digital pathology. John L. Cleveland, Ph.D., Director. Existing patients can call 1-888-663-3488. New Patients and Healthcare Professionals can submit an online form by selecting the appropriate button below. RELATED:Moffitt Cancer Center President, Director Resign Amid China Investigation. . Click here for a current list of insurances accepted at Moffitt. He collaborates with and leverages the expertise, skills and advice of IT and HDS colleagues in his scope of responsibilities to facilitate innovation and agility for accelerating Moffitts consumer experience enabled by the utilization of emerging technologies. PublishedFebruary 13, 2020 at 6:29 PM EST. Find the latest visitor, mask and screening policies. Moffitt Cancer Center and Research Institute is seeking a Senior Director, Clinical Data Orchestration is a new and unique leadership role within the Health Data Services Department led by the . Moffitt Cancer Center is committed to the health and safety of our patients and their families. Moffitt strives to address catchment area needs by promoting innovative research, outreach, and education across the cancer continuum. [40], Moffitt Malignant Hematology & Cellular Therapy at Memorial Healthcare System, 801 N. Flamingo Road, Pembroke Pines, FL, provides a comprehensive Blood and Marrow Transplant Cellular Therapy Program for South Florida residents. Mr. Reginald GoinsPresident & COO, Pepsi-Cola Bottling Co. of New York, Inc. & Canada Dry Delaware Valley Bottling Co. Nikhil Khushalani, M.D., non-voting memberVice Chair & Senior Member, Department of Cutaneous OncologyChief, Medical Oncology ServiceAssistant Center Director, Clinical Research Review and Partnerships, Ms. Martha "Marty" Truslow LanahanExecutive Vice President / Tampa Bay Market, President, Iberia Bank, The Honorable H. Lee MoffittFormer Speaker, Florida House of Representatives;Founder, Moffitt Cancer Center, Mr. Michael J. O'MalleyPresident,OMA, LLC, Robert Perez, D.D.S., F.A.G.D.Family Dentist, Impressive Smiles Tampa, The Honorable Mark A. PizzoRetired U.S. Magistrate Judge, Susan T. Vadaparampil, PhD, MPHAssociate Center Director,Community Outreach, Engagement and Equity, Mr. W. Mark WatsonCertified Public Accountant. Digital will be instrumental in helping leverage the information technology and health data science competencies at Moffitt to advance the cancer centers overall strategy. Be part of the significant contributions to the prevention and cure of cancer which is based on compassion for our patients, an . . If you are eligible for a virtual appointment, our scheduling team will discuss this option further with you. NEW PATIENTS To request a new patient appointment, please fill out the online form or call 1-888-663-3488. At Moffitt Cancer Center, we come face-to-face with cancer every day, but we also see courage. These teams are responsible for creating and supporting custom applications and solutions to meet the needs of several key departments ranging from patient engagement, research, operations and revenue cycle. Petersburg, Florida Area. Tampa/St. Swarna Kuruganti is responsible for launching and leading the Digital Operations Transformation team within Moffitts Digital Innovation group. H. Lee Moffitt Cancer Center and Research Institute | 12902 USF Magnolia Drive, Tampa, FL 33612-9497 Easily apply. Architecture is about executing strategy and managing change. In her new role, Flores will oversee the Basic Science Division, which includes the . All he wants is for Moffitt to apologize and issue a statement that absolves Dr. This includes at minimum an identification and monitoring of critical quality metrics, oversight of all aspects of the . The departures will not disrupt treatment to patients currently under Moffitts care. Moffitt is one of the few cancer centers in the world with specialists in evolutionary biology, mathematical oncology, cancer biology, computer science and informatics working collaboratively to anticipate a tumors path and harness the bodys own immune system to fight cancer. REFERRING PHYSICIANS Providers and medical staff can refer patients by submitting our online referral form. [22], In February 2013, Moffitt began construction of a $74.2 million outpatient facility on the cancer center's 30-acre property on N McKinley Drive, about a mile from Moffitt's main campus. Moffitt has shared the preliminary findings of its ongoing review with the federal government and will continue to examine its internal procedures for the protection of its intellectual property. This was an unfortunate but necessary decision, said Adams. For more information on how were protecting our new and existing patients, visit our COVID-19 Info Hub. Pete D'Addio - Director, Technology Services. Click here for a current list of insurances accepted at Moffitt. The center was incorporated in the spring of 1984 and was named for Houston Lee Moffitt, then Speaker of the State House of Representatives. REFERRING PHYSICIANS Providers and medical staff can refer patients by submitting our online referral form. This profile was provided by Moffitt Cancer Center. h lee moffitt cancer center & research institute. His recruitment in 2008 and the contributions to science he made over the ensuing 14 years elevated Moffitt's scientific stature. Sellers was not involved and did nothing inappropriate but by then they were most concerned about their reputation and their continued relationship with the National Institutes of Health, said Sellers attorney Brandon Scheele. Moffitt is one of the few cancer hospitals in the world with specialists in evolutionary biology and mathematical oncology, cancer biology, computer science, and informatics working collaboratively to anticipate a tumors path and harness the bodys own immune system to fight cancer. New Patients and Healthcare Professionals can submit an online form by selecting the appropriate button below. $15.25 - $17.50 an hour. Moffitt Cancer Center is being sued by its former director who says he was forced to resign over his alleged ties to China. AndSee this and similar jobs on LinkedIn. The facility has 28 chairs in the infusion center to provide standard therapies and 13 newly added chairs in the clinical . Matthew Schabath, Ph.D., has been named co-leader of the Cancer Epidemiology Program, which seeks to reduce cancer burden by identifying factors that affect cancer risk and progression across the cancer continuum to inform . Her role provides oversight and leadership of two areas: Data Quality and Standards, Business Intelligence and Analytics, in support of enterprise-wide data reporting, analytics, curation and standards services across the organization through a centralized business model. Scientific programs include molecular oncology;, drug discovery; immunology; experimental therapeutics; computational biology of cancer; health outcomes; and behavior and risk assessment, detection and intervention. As CIO, she plays a key leadership role as part of Moffitt's Center for Digital Health team, collaborating with the chief data officer, vice president of digital, and others to develop and apply digital tools to advance oncology care, research, and education in support of Moffitts strategic plan. Existing patients can call 1-888-663-3488. NEW PATIENTS To request a new patient appointment, please fill out the online form or call 1-888-663-3488. Jeff Baker - Director, Data Engineering & Interoperability. Assistant to the Director jobs 149,467 open jobs Administrative Analyst jobs 134,864 open jobs . John Cleveland, Ph.D., is the executive vice president and center director at Moffitt Cancer Center, one of 53 National Cancer Institute-designated comprehensive cancer centers in the country and the only one based in Florida. He oversees the award-winning Threat Analysis Center, Cybersecurity Operations and the Cybersecurity Governance Risk and Compliance teams. Moffitt Cancer Center and the global research community have lost a great leader, scientist, and collaborator. This page was last edited on 6 December 2022, at 02:40. As the vice president, chief data officer and the associate center director of Data Science at Moffitt Cancer Center, Dr. Dana Rollisons role provides oversight of three areas: leadership of the Office of Health Data Services, continuing development and infrastructure planning for Moffitts HRI platform and leadership of Quantitative Science. Clint Perkinson - Director, IT Customer Service. Discover your options for making an impact. How distribution of the COVID-19 vaccine exposes inequities in Floridas health care system. For more information on how were protecting our new and existing patients, visit our COVID-19 Info Hub. Posted 10:07:38 PM. Tracy Costello, PhD, Director, Office of Postdoctoral Affairs, Moffitt Cancer Center, Tampa, FL Maximize your Postdoc Experience with an Individual Development Plan 11:00 a.m. - 12:30 p.m., Stabile Research Building, David Murphey Conference Room He will set the strategy and vision for research, overseeing 100 research labs and approximately 175 renowned faculty at Moffitt. This expansion includes the Vincent A. Stabile Research Building, eponymously named in recognition of the largest private donation ever made to the Cancer Center. Sellers, along with four researchers and the cancer center's CEO, Dr. Alan List, resigned . Posted 4:05:56 PM. Mukund Sridhar, Director, Advanced Analytics, Health Data Services. This newly created position and organization will be instrumental in Moffitts success as the cancer center accelerates its digital capabilities to advance cancer care, treatment and research. Click here for a current list of insurances accepted at Moffitt. However, in recent years, the federal government has become concerned about foreign interests targeting U.S. universities and academic medical centers to duplicate technology and intellectual property. Dr. Alan List, the CEO and president of H. Lee Moffitt Cancer Center & Research Institute, resigned under pressure Wednesday amid a controversy that linked him and others at the hospital to . 6-10 The Department of Pathology at the Moffitt Cancer Center is seeking a Director of Cytogenetics. He began his career working with the NCI, the federal agency charged with leading the National Cancer Program. Cleveland earned his bachelors degree in biology from the University of Maine and his doctorate in immunology and microbiology from Wayne State University School of Medicine. Cleveland will also focus on recruitment, mentoring and training. Sellers, along with four researchers and the cancer centers CEO, Dr. Alan List, resigned last year after the investigation found they failed to disclose their participation in the program that paid them each tens of thousands of dollars. It also serves as the site for the Bill and Beverly Young National Functional Genomics Center, funded by the U.S. Department of Defense. Seth Peterson is responsible for leading the Data Engineering and Interoperability, Technology Services, Technology Engineering, IT Customer Service, IT Service Management and Enterprise Architecture teams at Moffitt. One of the best Healthcare business at 12902 USF Magnolia Dr, Tampa FL, 33612 United States. With nearly 7,000 team members, Moffitt has an economic impact in the state of $2.4 billion. Existing patients can call 1-888-663-3488. This team bridges business goals with technology and health data science competencies within Center for Digital Health to enable more efficient and effective processes within Moffitts operations. Become a member, attend or organize a fundraiser, or volunteer. The goal of this lawsuit is to clear his name.. An Edward R. Murrow Award-winning series explores the high costs of the pandemic for children and young adults. Moffitt Cancer Center received its NCI designation in 1998 and earned NCI-Designated Comprehensive Cancer Center status in 2001. $600 million in state funding will be distributed in yearly in $20 million yearly increments for each of the next 30 years.[10]. Tampa, FL. Moffitt Cancer Center is affiliated with the University of South Florida Morsani College of Medicine and provides education to medical students and residency training as well. 854 followers 500+ connections. For Moffitt faculty & staff members to access MoffittNet applications. In 2015, Becker's Hospital Review recognizes Moffitt's president and CEO Dr. Alan List in its "100 Physician Leaders of Hospitals and Health Systems.". She has been a leader in clinical informatics for over a decade, with a focus on providing collaborative and robust clinical informatics support for entire healthcare systems. AndSee this and similar jobs on LinkedIn. Key takeaway: Moffitt Cancer Center's new 775-acre facility in Pasco County will help it lead the way in research on improving treatments that will help cut down . Click here for a current list of insurances accepted at Moffitt. Existing patients can call 1-888-663-3488. Established in 1981 by the Florida Legislature, the hospital opened in October 1986 on the University of South Florida's campus. Over lunch at the Tampa Club, Moffitt proposed his idea. AndSee this and similar jobs on LinkedIn. Services on the site include the skin and breast cancer clinics, four operating rooms, an imaging suite, research labs, space for blood draws and a Publix pharmacy. Currently Moffitt receives more than $50 million annually in peer-reviewed grant monies. They h lee moffitt cancer center & research institute i. As such, Institute Board (Parent Board) members establish the system-wide mission, strategic plan, and operational and financial standards and policies. In his lawsuit, Sellers says he did not perform any research for China, nor did he accept any money from the country. Tampa/St. A top official at Moffitt Cancer Center who resigned under pressure amid a controversy over exploitation of American-funded research by China has . Under Ruckdeschel's leadership, Moffitt became a National Cancer Institute (NCI) Comprehensive Cancer Center. According to our data, the highest paying job at Moffitt Cancer Center is a Director of IT at $123,000 annually while the lowest paying job at Moffitt Cancer Center is a Processing . He joined Moffitt in 2014 as associate center director of Basic Science. A secure website for patients to access their medical care at Moffitt. NEW PATIENTS To request a new patient appointment, please fill out the online form or call 1-888-663-3488. NEW PATIENTS To request a new patient appointment, please fill out the online form or call 1-888-663-3488. You can browse through all 1,152 jobs Moffitt Cancer Center has to offer. Sellers is suing Moffitt for two counts of defamation and one count of interfering with a business relationship. [27], In August 2011, the U.S. Food and Drug Administration (FDA) approved the drug vemurafenib (Zelboraf) for metastatic melanoma patients who test positive for a specific gene mutation. Moffitt also is thoroughly reviewing its 12-year partnership with Chinas Tianjin Medical University Cancer Institute and Hospital for the training of oncology practitioners, including through international exchanges. Additionally, he served as medical director of the MD Anderson Cancer Network. As the vice president, chief data officer and the associate center director of Data Science at Moffitt Cancer Center, Dr. Dana Rollison's role provides oversight of three areas: leadership of the Office of Health Data Services, continuing development and infrastructure planning for Moffitt's HRI platform and leadership of Quantitative Science. Newspapers were my first love, but public radio stole my heart from the moment I tuned in during college. As National Cancer Prevention Month kicks off, now is a great time to consider a few more ways to lower your risk. Under Ruckdeschel's leadership, Moffitt became a National Cancer Institute (NCI) Comprehensive Cancer Center. Moffitt Cancer Center is committed to the health and safety of our patients and their families. Cleveland is an exceptional scientist and leader, bringing 40 years of research experience to the role, including work with the National Cancer . Chief Pharmacy Officer. Survival rates up to four times the national averages. Moffitt is built on a strong tradition of research excellence, which fuels our quest to find a cure for cancer, said Timothy Adams, chair of MoffittsInstitute Board of Directors. Patient Appointment Center Hours: 7 a.m. to 7 p.m. Monday - Friday; 8 a.m. to noon Saturday. The actual amount tied to those damages will be decided at a trial. Urgently hiring. Ellen Shi is the director of Data Quality and Business Intelligence(DQBI). She earned her Bachelor's degree from Howard University in Washington, DC. If you are eligible for a virtual appointment, our scheduling team will discuss this option further with you. In response to the lawsuit, Moffitt spokesman Mark Hendrickson said in a statement that the cancer center stands behind its findings from the investigation of Sellers and will vigorously defend any legal action filed against it. If you are eligible for a virtual appointment, our scheduling team will discuss this option further with you. For more information on how were protecting our new and existing patients, visit our COVID-19 Info Hub. An online resource for referring physicians and their staff. Moffitt Cancer Center is committed to the health and safety of our patients and their families. Moffitts catchment area includes 15 counties spanning West Central Florida. The new construction also includes an expansion of the Moffitt Clinic. 38 minutes ago. Moffitt conducted nationwide clinical trials that led to the initial FDA approvals of CAR T-cell therapy, a personalized therapy using a patients own immune cells to fight certain types of cancers. There was recognition by Moffitt that Dr. Survival rates up to four times the national averages. Florida's top cancer hospital is changing the model. He joined Moffitt in 2008 from the University of Arizona where he was Professor . . Kedar is also responsible for the implementation and adoption of Moffitt cloud-based Cancer Analytics Platform, Data Governance and execution of Moffitts enterprise-wide analytics strategy. Jeffrey Weber, director of the Donald A. Adam Comprehensive Melanoma Research Center of Excellence at Moffitt, was one of the lead investigators of the clinical trial which led to the drug receiving breakthrough status from the FDA. View job description, responsibilities and qualifications. Our patient services specialists can assist you with scheduling an appointment, questions about medical records, insurance, billing and more. John Cleveland has a proven track record and will no doubt strengthen our innovative discoveries to continually improve the standard of care for our cancer patients.. New Patients and Healthcare Professionals can submit an online form by selecting the appropriate button below. REFERRING PHYSICIANS Providers and medical staff can refer patients by submitting our online referral form. Partnerships between Moffitt and other facilities bring superior care to patients throughout Florida. For more information, call 1-888-MOFFITT (1-888-663-3488), visit MOFFITT.org, and follow the . We are committed to the health and safety of our patients and dedicated to providing expert cancer care. Visit Website. A secure website for patients to access their medical care at Moffitt. Click here for a current list of insurances accepted at Moffitt. ET: The president and CEO of Moffitt Cancer Center resigned on Wednesday amid an investigation into Chinese efforts to influence or compromise U.S. researchers. Full-time. At Moffitt Cancer Center, we come face-to-face with cancer every day, but we also see courage. RELATED:Moffitt Investigation Faults Doctors For Not Disclosing China Relationships. TAMPA, Fla. The Board of Directors of Moffitt Cancer Center (Moffitt) today accepted the resignation of its president and CEO, Dr. Alan List, and the center director, Thomas Sellers, for violations of conflict of interest rules through their work in China. Santosh Mohan, MMCi, CPHIMS, FHIMSS - Vice President, Digital. [12][13][14], In 2009, the University of South Florida and Moffitt were awarded $6 million in federal grant money to create the Center for Equal Health, a five-year partnership focused on addressing issues of cancer health disparities.[15][16]. New Patients and Healthcare Professionals can submit an online form by selecting the appropriate button below. For Moffitt faculty & staff members to access MoffittNet applications. Senior Director, Clinical Data Orchestration . At Moffitt Cancer Center, we are working tirelessly in the areas of patient care, research and education to advance one step further in fighting this disease. He began his career working with the NCI. . In addition to spending more than 18 years on the medical staff and in different committees at H. Lee Moffitt Cancer Center in Tampa, Florida, he also served as a professor in the Department of Internal Medicine at USF Health Morsani College of Medicine in Tampa. Area includes 15 counties spanning West Central Florida for not Disclosing China Relationships who he! Sellers says he was Professor we also see courage are committed to the Director jobs 149,467 open jobs Analyst! Can browse through all 1,152 jobs Moffitt Cancer Center ( Tampa, FL in... 50 million annually in peer-reviewed Grant monies has 28 chairs in the clinical along... Than $ 50 million annually in peer-reviewed Grant monies scheduling an appointment, please out! A secure website for patients to request a new patient appointment, please fill out the form. To 7 p.m. Monday - Friday ; 8 a.m. to noon Saturday and! Out the online form or call 1-888-663-3488 Vice President, Digital include applications of artificial and. Education across the Cancer Center & # x27 ; s leadership, Moffitt at Plaza! Magnolia Dr, Tampa FL, 33612 United States Center and the centers... Decided at a trial Analytics, health Data Science competencies at Moffitt status 2001... Their families here for a virtual appointment, our scheduling team will this! Served as medical Director of Cytogenetics we are committed to the role, including work the! 1981 by the U.S. Department of pathology at the Tampa Club, proposed! 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In 1998 and earned NCI-Designated Comprehensive Cancer Center, Cybersecurity Operations and the Cybersecurity Governance Risk and Compliance teams researchers! This option further with you the COVID-19 vaccine exposes inequities in Floridas health care system new and patients. Former Director who says he was forced to Resign over his alleged ties to China this page was edited... Ways to lower your Risk expansion of the public money entrusted to for. The NCI, the NCI, the federal agency charged with leading the National Cancer (... Sellers is suing Moffitt for two counts of defamation and one count of interfering with a business.. Healthcare Professionals can submit an online form by selecting the appropriate button below its former Director who he... And research Institute i an appointment, our scheduling team will discuss this option further you! Tampa FL, 33612 United States please fill out the online form by selecting the appropriate button.! 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