MEDICARE: MIDWAY PRIMARY CARE 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	207R00000X	Internal Medicine Physician

Other Identifiers

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

General Provider Information

NPI Number	:	1598114779
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIDWAY PRIMARY CARE LLC

Provider Business Mailing Address
First Line	:	356 E MIDWAY RD
Second Line	:
City	:	FORT PIERCE
State	:	FL
Zip	:	34982-7148
Country	:	US
Telephone Number	:	772-464-9746
Fax Number	:

Provider Business Practice Location Address
First Line	:	3255 S US HIGHWAY 1
Second Line	:
City	:	FORT PIERCE
State	:	FL
Zip	:	34982-6381
Country	:	US
Telephone Number	:	772-742-9470
Fax Number	:

Authorized Official
Title or Position	:	BOARD MEMBER
Name	:	KATHRYN HAYDEN
Credential	:
Telephone Number	:	772-464-9746

Provider Enumeration Date	:	06/08/2016
Last Update Date	:	06/24/2022

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