Healthcare Provider Details

I. General information

NPI: 1841908563
Provider Name (Legal Business Name): FASTMD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2022
Last Update Date: 11/10/2022
Certification Date: 11/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11319 CORTEZ BLVD
BROOKSVILLE FL
34613-5407
US

IV. Provider business mailing address

11319 CORTEZ BLVD
BROOKSVILLE FL
34613-5407
US

V. Phone/Fax

Practice location:
  • Phone: 352-556-2524
  • Fax: 352-597-2243
Mailing address:
  • Phone: 352-556-2524
  • Fax: 352-597-2243

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number
License Number State

VIII. Authorized Official

Name: FARHAN N SIDDIQI
Title or Position: PRESIDENT
Credential: MD
Phone: 727-807-2476