Healthcare Provider Details

I. General information

NPI: 1396200283
Provider Name (Legal Business Name): PHYSICIAN PROVIDERS GROUP PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2019
Last Update Date: 07/03/2023
Certification Date: 07/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3120 SW 27TH AVE STE 300
OCALA FL
34471-8984
US

IV. Provider business mailing address

PO BOX 1925
LADY LAKE FL
32158-1925
US

V. Phone/Fax

Practice location:
  • Phone: 352-344-4791
  • Fax: 352-344-3822
Mailing address:
  • Phone: 352-553-4075
  • Fax: 888-770-3208

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: ROBERT ULSETH
Title or Position: OWNER
Credential: MD
Phone: 352-553-4075