MEDICARE: NORDQUIST FAMILY MEDICAL CENTER MD 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	207Q00000X	Family Medicine Physician	ME103291	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	ME103291	OTHER	FL	FL MEDICAL LICENSE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1770867269
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORDQUIST FAMILY MEDICAL CENTER MD PA

Provider Business Mailing Address
First Line	:	1925 DON WICKHAM DR
Second Line	:
City	:	CLERMONT
State	:	FL
Zip	:	34711-1915
Country	:	US
Telephone Number	:	352-638-7900
Fax Number	:	877-444-2394

Provider Business Practice Location Address
First Line	:	1925 DON WICKHAM DR
Second Line	:
City	:	CLERMONT
State	:	FL
Zip	:	34711-1915
Country	:	US
Telephone Number	:	352-638-7900
Fax Number	:	877-444-2394

Authorized Official
Title or Position	:	PRESIDENT
Name	:	CLAY E NORDQUIST
Credential	:	MD
Telephone Number	:	352-638-7900

Provider Enumeration Date	:	10/04/2011
Last Update Date	:	10/04/2011

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