Healthcare Provider Details

I. General information

NPI: 1801263983
Provider Name (Legal Business Name): HEALTHY FAMILY MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2015
Last Update Date: 02/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1138 NIKKI VIEW DR
BRANDON FL
33511-4868
US

IV. Provider business mailing address

PO BOX 891293
TAMPA FL
33689-1100
US

V. Phone/Fax

Practice location:
  • Phone: 813-393-1500
  • Fax: 813-393-1501
Mailing address:
  • Phone: 813-393-1500
  • Fax: 813-393-1501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number94636
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberACN415
License Number StateFL

VIII. Authorized Official

Name: JULIA BERESFORD
Title or Position: SECRETARY
Credential:
Phone: 340-642-3813