Healthcare Provider Details

I. General information

NPI: 1598114779
Provider Name (Legal Business Name): MIDWAY PRIMARY CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2016
Last Update Date: 06/24/2022
Certification Date: 06/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3255 S US HIGHWAY 1
FORT PIERCE FL
34982-6381
US

IV. Provider business mailing address

356 E MIDWAY RD
FORT PIERCE FL
34982-7148
US

V. Phone/Fax

Practice location:
  • Phone: 772-742-9470
  • Fax:
Mailing address:
  • Phone: 772-464-9746
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: KATHRYN HAYDEN
Title or Position: BOARD MEMBER
Credential:
Phone: 772-464-9746