Healthcare Provider Details

I. General information

NPI: 1700181005
Provider Name (Legal Business Name): MANATEE PHYSICIAN ALLIANCE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2011
Last Update Date: 01/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8340 LAKEWOOD RANCH BLVD SUITE 140
LAKEWOOD RANCH FL
34202-5180
US

IV. Provider business mailing address

PO BOX 281741
ATLANTA GA
30384-1741
US

V. Phone/Fax

Practice location:
  • Phone: 941-782-2800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: EUGENNIA JENNINGS
Title or Position: PRACTICE MANAGER
Credential:
Phone: 941-753-7585