Healthcare Provider Details

I. General information

NPI: 1366687923
Provider Name (Legal Business Name): FAMILY MEDICAL PRACTICE MANAGEMENT, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2008
Last Update Date: 12/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

645 RIDGEWOOD AVE
HOLLY HILL FL
32117-3617
US

IV. Provider business mailing address

645 RIDGEWOOD AVE
HOLLY HILL FL
32117-3617
US

V. Phone/Fax

Practice location:
  • Phone: 386-258-5476
  • Fax:
Mailing address:
  • Phone: 386-258-5476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: JOHN A LEVIN
Title or Position: SECRETARY
Credential:
Phone: 386-258-5476