MEDICARE: MID-FLORIDA PSYCHIATRY CENTER PL

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)	ME82811	FL

General Provider Information

NPI Number	:	1376599472
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MID-FLORIDA PSYCHIATRY CENTER PL

Provider Business Mailing Address
First Line	:	2504 SAND MINE RD
Second Line	:
City	:	DAVENPORT
State	:	FL
Zip	:	33897-3402
Country	:	US
Telephone Number	:	863-419-7645
Fax Number	:

Provider Business Practice Location Address
First Line	:	2504 SAND MINE RD
Second Line	:
City	:	DAVENPORT
State	:	FL
Zip	:	33897-3402
Country	:	US
Telephone Number	:	863-419-7645
Fax Number	:

Authorized Official
Title or Position	:	MANAGER MEMBER
Name	:	VIDYASAGAR REDDY VANGALA
Credential	:
Telephone Number	:	863-419-7645

Provider Enumeration Date	:	05/26/2006
Last Update Date	:	11/22/2010

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