MEDICARE: VILLAGES INTERNAL MEDICINE AND SENIOR CLINIC 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	207RG0300X	Geriatric Medicine (Internal Medicine) Physician	ME80483	FL
2	207R00000X	Internal Medicine Physician	ME80483	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	58634	OTHER	FL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1801939277
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VILLAGES INTERNAL MEDICINE AND SENIOR CLINIC PA

Provider Business Mailing Address
First Line	:	3351 WEDGEWOOD LN
Second Line	:
City	:	THE VILLAGES
State	:	FL
Zip	:	32162-7181
Country	:	US
Telephone Number	:	352-259-0634
Fax Number	:	352-259-2174

Provider Business Practice Location Address
First Line	:	3351 WEDGEWOOD LN
Second Line	:
City	:	THE VILLAGES
State	:	FL
Zip	:	32162-7181
Country	:	US
Telephone Number	:	352-259-0634
Fax Number	:	352-259-2174

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. WINSTON EVALLE
Credential	:	M.D.
Telephone Number	:	352-259-0364

Provider Enumeration Date	:	02/15/2007
Last Update Date	:	11/29/2010

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Directions to “VILLAGES INTERNAL MEDICINE AND SENIOR CLINIC PA ” Practice Location

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