Healthcare Provider Details

I. General information

NPI: 1780911925
Provider Name (Legal Business Name): CENTRAL FLORIDA INJURY SOUTHWEST, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2009
Last Update Date: 06/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

882 S KIRKMAN RD STE 101
ORLANDO FL
32811-2652
US

IV. Provider business mailing address

882 S KIRKMAN RD STE 101
ORLANDO FL
32811-2652
US

V. Phone/Fax

Practice location:
  • Phone: 407-578-2350
  • Fax: 407-264-8300
Mailing address:
  • Phone: 407-578-2350
  • Fax: 407-264-8300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number StateFL

VIII. Authorized Official

Name: MR. JEROLD J FADEM JR.
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 407-578-2351