Healthcare Provider Details

I. General information

NPI: 1629138292
Provider Name (Legal Business Name): FLORIDA CLINICAL PRACTICE ASSOCIATION INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 12/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25827 SE HIGHWAY 19
OLD TOWN FL
32680-3997
US

IV. Provider business mailing address

PO BOX 13833
PHILADELPHIA PA
19101-3833
US

V. Phone/Fax

Practice location:
  • Phone: 352-265-7922
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM W THARP
Title or Position: EXECUTIVE VICE PRESIDENT
Credential:
Phone: 352-265-8017