MEDICARE: DR. LYDIA KEFALIDOU MD

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	207R00000X	Internal Medicine Physician	ME93402	FL

General Provider Information

NPI Number	:	1508833427
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LYDIA KEFALIDOU MD

Provider Business Mailing Address
First Line	:	264 PALM COAST PKWY NE
Second Line	:	STE A
City	:	PALM COAST
State	:	FL
Zip	:	32137-8217
Country	:	US
Telephone Number	:	386-446-5505
Fax Number	:	386-446-5077

Provider Business Practice Location Address
First Line	:	264 PALM COAST PKWY NE
Second Line	:	STE A
City	:	PALM COAST
State	:	FL
Zip	:	32137-8217
Country	:	US
Telephone Number	:	386-446-5505
Fax Number	:	386-446-5077

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/01/2006
Last Update Date	:	07/08/2007

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