Healthcare Provider Details

I. General information

NPI: 1174834717
Provider Name (Legal Business Name): AMA MEDICAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2010
Last Update Date: 11/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 PATRICIA AVE UNITS B & D
DUNEDIN FL
34698-8100
US

IV. Provider business mailing address

PO BOX 306
PALM HARBOR FL
34682-0306
US

V. Phone/Fax

Practice location:
  • Phone: 727-331-8740
  • Fax: 727-331-8744
Mailing address:
  • Phone: 727-331-8740
  • Fax: 727-331-8744

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME 96750
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberME 96750
License Number StateFL

VIII. Authorized Official

Name: DR. CRUZ MARTINA FANA-SOUCHET
Title or Position: PRESIDENT/MEDICAL DIRECTOR
Credential: M.D.
Phone: 727-331-8740