Healthcare Provider Details

I. General information

NPI: 1487638219
Provider Name (Legal Business Name): INTERVENTIONAL MEDICAL ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2005
Last Update Date: 01/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6821 NW 11TH PL
GAINESVILLE FL
32605-4216
US

IV. Provider business mailing address

6821 NW 11TH PL
GAINESVILLE FL
32605-4216
US

V. Phone/Fax

Practice location:
  • Phone: 352-331-3353
  • Fax: 352-333-9035
Mailing address:
  • Phone: 352-331-3353
  • Fax: 352-333-9035

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberME76862
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberME82864
License Number StateFL

VIII. Authorized Official

Name: ROBYN GANN
Title or Position: PRACTICE MANAGER
Credential:
Phone: 352-331-3353