MEDICARE: MID FLORIDA PHYSICIANS GROUP INC.

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

General Provider Information

NPI Number	:	1629565932
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MID FLORIDA PHYSICIANS GROUP INC.

Provider Business Mailing Address
First Line	:	300 S MAIN ST STE 2
Second Line	:
City	:	WILDWOOD
State	:	FL
Zip	:	34785-4542
Country	:	US
Telephone Number	:	352-643-6699
Fax Number	:	888-643-6699

Provider Business Practice Location Address
First Line	:	300 S MAIN ST
Second Line	:
City	:	WILDWOOD
State	:	FL
Zip	:	34785-4542
Country	:	US
Telephone Number	:	352-643-6699
Fax Number	:	888-675-8377

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JERROLD RANDALL ECKLIND
Credential	:	DO
Telephone Number	:	386-290-6721

Provider Enumeration Date	:	04/23/2018
Last Update Date	:	06/28/2023

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