Healthcare Provider Details

I. General information

NPI: 1215099007
Provider Name (Legal Business Name): FAMILY MEDICAL GROUP PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2006
Last Update Date: 05/24/2021
Certification Date: 05/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 HEALTH WAY
LAKE PLACID FL
33852-8123
US

IV. Provider business mailing address

113 HEALTH WAY
LAKE PLACID FL
33852-8123
US

V. Phone/Fax

Practice location:
  • Phone: 863-465-7010
  • Fax:
Mailing address:
  • Phone: 863-465-7010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JOANNE E STAYTON
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 863-465-7010