MEDICARE: FAMILY PRACTICE,DR.ASSEFA LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2300X	Primary Care Clinic/Center	ME67444	FL

General Provider Information

NPI Number	:	1083913842
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY PRACTICE,DR.ASSEFA LLC

Provider Business Mailing Address
First Line	:	PO BOX 2627
Second Line	:
City	:	PALATKA
State	:	FL
Zip	:	32178-2627
Country	:	US
Telephone Number	:	386-329-3939
Fax Number	:	386-329-8990

Provider Business Practice Location Address
First Line	:	6100 SAINT JOHNS AVE STE 4
Second Line	:
City	:	PALATKA
State	:	FL
Zip	:	32177-6859
Country	:	US
Telephone Number	:	386-329-3939
Fax Number	:	386-329-8990

Authorized Official
Title or Position	:	MANAGER
Name	:	DR. IRENA MARIA ASSEFA
Credential	:	M.D.
Telephone Number	:	386-329-3939

Provider Enumeration Date	:	03/19/2011
Last Update Date	:	06/26/2012

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