MEDICARE: PRIMECARE MEDICAL 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	207Q00000X	Family Medicine Physician	ME73277	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	42524A	OTHER	FL	INDIVIDUAL MC PROVIDER #
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1861688814
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRIMECARE MEDICAL CLINIC, PA

Provider Business Mailing Address
First Line	:	2869 WILSHIRE DR
Second Line	:	SUITE 205
City	:	ORLANDO
State	:	FL
Zip	:	32835-3282
Country	:	US
Telephone Number	:	407-295-0500
Fax Number	:	407-290-2997

Provider Business Practice Location Address
First Line	:	2869 WILSHIRE DR
Second Line	:	SUITE 205
City	:	ORLANDO
State	:	FL
Zip	:	32835-3282
Country	:	US
Telephone Number	:	407-295-0500
Fax Number	:	407-290-2997

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MOHAMMED AK MOOSA
Credential	:	MD
Telephone Number	:	407-830-5080

Provider Enumeration Date	:	09/23/2007
Last Update Date	:	05/06/2010

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