Healthcare Provider Details

I. General information

NPI: 1356580518
Provider Name (Legal Business Name): MIDWAY IMMUNOLOGY AND RESEARCH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2009
Last Update Date: 02/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

356 E MIDWAY RD
FORT PIERCE FL
34982-7148
US

IV. Provider business mailing address

356 E MIDWAY RD
FORT PIERCE FL
34982-7148
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: MOTI N RAMGOPAL
Title or Position: CEO
Credential: MD
Phone: 772-464-9746