MEDICARE: FLORIDA ENT ADULT & PEDIATRIC PA

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	207Y00000X	Otolaryngology Physician	ME0077191	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	AB304	OTHER	FL	MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1316908353
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FLORIDA ENT ADULT & PEDIATRIC PA

Provider Business Mailing Address
First Line	:	1162 CYPRESS GLEN CIR
Second Line	:
City	:	KISSIMMEE
State	:	FL
Zip	:	34741-7560
Country	:	US
Telephone Number	:	407-343-9006
Fax Number	:	407-343-0999

Provider Business Practice Location Address
First Line	:	1162 CYPRESS GLEN CIR
Second Line	:
City	:	KISSIMMEE
State	:	FL
Zip	:	34741-7560
Country	:	US
Telephone Number	:	407-343-9006
Fax Number	:	407-343-0999

Authorized Official
Title or Position	:	PHYSICIAN ENT SPECIALIST
Name	:	OMAR FADHLI
Credential	:	MD
Telephone Number	:	407-343-9006

Provider Enumeration Date	:	03/29/2006
Last Update Date	:	11/09/2021

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Directions to “FLORIDA ENT ADULT & PEDIATRIC PA ” Practice Location

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