Healthcare Provider Details

I. General information

NPI: 1407884018
Provider Name (Legal Business Name): MARIE RAIME M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 12/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1283 SW STATE ROAD 47 SUITE 103
LAKE CITY FL
32025-0489
US

IV. Provider business mailing address

PO BOX 3412
LAKE CITY FL
32056-3412
US

V. Phone/Fax

Practice location:
  • Phone: 386-754-0339
  • Fax: 306-754-0393
Mailing address:
  • Phone: 386-754-0339
  • Fax: 386-754-0593

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME85010
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: