Healthcare Provider Details

I. General information

NPI: 1093493637
Provider Name (Legal Business Name): ADVENTHEALTH PRIMARY CARE NETWORK INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2023
Last Update Date: 09/15/2023
Certification Date: 09/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 HOPE WAY
ALTAMONTE SPRINGS FL
32714-1502
US

IV. Provider business mailing address

900 HOPE WAY
ALTAMONTE SPRINGS FL
32714-1502
US

V. Phone/Fax

Practice location:
  • Phone: 407-357-1000
  • Fax:
Mailing address:
  • Phone: 407-357-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: KELLY J PETTIJOHN
Title or Position: SVP-CFO
Credential:
Phone: 407-357-1000