Healthcare Provider Details

I. General information

NPI: 1497255814
Provider Name (Legal Business Name): PLANTATION MEDICAL CARE, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2018
Last Update Date: 06/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9030 W FORT ISLAND TRL STE 11B
CRYSTAL RIVER FL
34429
US

IV. Provider business mailing address

9030 W FORT ISLAND TRL STE 11B
CRYSTAL RIVER FL
34429-2415
US

V. Phone/Fax

Practice location:
  • Phone: 352-651-5127
  • Fax: 352-651-5129
Mailing address:
  • Phone: 352-651-5127
  • Fax: 352-651-5129

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberOS-0004310
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberOS4310
License Number StateFL

VIII. Authorized Official

Name: ADRIANNE ASHMORE HESS
Title or Position: OFFICE MANAGER
Credential:
Phone: 352-651-5127