Healthcare Provider Details

I. General information

NPI: 1104268341
Provider Name (Legal Business Name): FAMILY MEDICAL EXPRESS AND RIVERVIEW PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2013
Last Update Date: 07/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 W ROBERTSON ST
BRANDON FL
33511-5111
US

IV. Provider business mailing address

107 W ROBERTSON ST
BRANDON FL
33511-5111
US

V. Phone/Fax

Practice location:
  • Phone: 813-438-8947
  • Fax: 813-438-8940
Mailing address:
  • Phone: 813-438-8947
  • Fax: 813-438-8940

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. YVONNE CLARKE
Title or Position: PRES
Credential: ARNP
Phone: 813-438-8947