Healthcare Provider Details

I. General information

NPI: 1174719629
Provider Name (Legal Business Name): RAIMAH PRIMARY CARE CENTER PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2007
Last Update Date: 12/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

1283 SW STATE ROAD 47 SUITE103
LAKE CITY FL
32025-0489
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberME85010
License Number StateFL

VIII. Authorized Official

Name: DR. MARIE RAIME
Title or Position: DOCTOR
Credential: MD
Phone: 386-754-0339