Healthcare Provider Details

I. General information

NPI: 1588036040
Provider Name (Legal Business Name): PHYSICIANS COLLABORATIVE AFFILIATES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2015
Last Update Date: 08/17/2023
Certification Date: 08/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 E MILLER ST
ORLANDO FL
32806-2123
US

IV. Provider business mailing address

501 N ORLANDO AVE SUITE 313, PMB 185
WINTER PARK FL
32789-7313
US

V. Phone/Fax

Practice location:
  • Phone: 407-803-4016
  • Fax: 407-803-4045
Mailing address:
  • Phone: 407-803-4016
  • Fax: 407-803-4045

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. ROCCO CONIGLIO
Title or Position: PRESIDENT
Credential:
Phone: 330-523-0593