MEDICARE: OUTCOME BASED DELIVERY SYSTEMS ACQUISITION COMPANY, 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	207Q00000X	Family Medicine Physician	ME103291	FL

General Provider Information

NPI Number	:	1205062163
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OUTCOME BASED DELIVERY SYSTEMS ACQUISITION COMPANY, LLC

Provider Business Mailing Address
First Line	:	2929 N UNIVERSITY DR
Second Line	:	SUITE # 110
City	:	CORAL SPRINGS
State	:	FL
Zip	:	33065-5081
Country	:	US
Telephone Number	:	954-656-8855
Fax Number	:

Provider Business Practice Location Address
First Line	:	1120 CITRUS TOWER BLVD
Second Line	:	SUITE # 300
City	:	CLERMONT
State	:	FL
Zip	:	34711-1909
Country	:	US
Telephone Number	:	352-243-0206
Fax Number	:

Authorized Official
Title or Position	:	BILLING MANGER
Name	:	PATEESHA BRUTEN
Credential	:
Telephone Number	:	954-656-8855

Provider Enumeration Date	:	06/05/2009
Last Update Date	:	11/23/2009

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