Healthcare Provider Details

I. General information

NPI: 1003577081
Provider Name (Legal Business Name): SPARTAN MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2022
Last Update Date: 01/10/2022
Certification Date: 01/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9145 NARCOOSSEE RD STE A102
ORLANDO FL
32827-5768
US

IV. Provider business mailing address

10524 MOSS PARK RD STE 204-771
ORLANDO FL
32832-5898
US

V. Phone/Fax

Practice location:
  • Phone: 407-703-6020
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: KWABENA AMPONSAH
Title or Position: CEO/PROVIDER
Credential:
Phone: 937-902-2068