Healthcare Provider Details

I. General information

NPI: 1982004933
Provider Name (Legal Business Name): OLD TOWN MEDICAL CENTERS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2014
Last Update Date: 08/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 TRUMAN AVE
KEY WEST FL
33040-3141
US

IV. Provider business mailing address

540 TRUMAN AVE
KEY WEST FL
33040-3141
US

V. Phone/Fax

Practice location:
  • Phone: 305-394-1792
  • Fax:
Mailing address:
  • Phone: 305-394-1792
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME 51339
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberOS9185
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number9168222
License Number StateFL

VIII. Authorized Official

Name: TIMOTHY MACKEY
Title or Position: AP
Credential: DO
Phone: 305-394-1792