Healthcare Provider Details

I. General information

NPI: 1942795869
Provider Name (Legal Business Name): ST PETER MEDICAL GROUP INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2018
Last Update Date: 09/16/2024
Certification Date: 09/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

339 CYPRESS PKWY STE 110
KISSIMMEE FL
34759
US

IV. Provider business mailing address

PO BOX 582170
KISSIMMEE FL
34758-0027
US

V. Phone/Fax

Practice location:
  • Phone: 407-922-0240
  • Fax: 407-343-5199
Mailing address:
  • Phone: 407-922-0240
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MIRIAM L RIVERA-IRIZARRY
Title or Position: CEO
Credential: MD
Phone: 407-729-8173