Healthcare Provider Details

I. General information

NPI: 1629814512
Provider Name (Legal Business Name): FL MOBILE MEDICAL PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2024
Last Update Date: 08/23/2024
Certification Date: 08/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4033 TAMPA RD STE 100
OLDSMAR FL
34677-3224
US

IV. Provider business mailing address

81 HOLLY HILL LN FL 3
GREENWICH CT
06830-2945
US

V. Phone/Fax

Practice location:
  • Phone: 203-869-5515
  • Fax: 203-869-5765
Mailing address:
  • Phone: 203-869-5515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: GLENN GANDELMAN
Title or Position: OWNER
Credential: MD
Phone: 917-477-9028