Healthcare Provider Details

I. General information

NPI: 1538614979
Provider Name (Legal Business Name): SILVERSAGE PHYSICIAN SERVICES OF FLORIDA, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2016
Last Update Date: 01/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 VILLA NUEVA AVE NE
PALM BAY FL
32907-2595
US

IV. Provider business mailing address

PO BOX 22784
CHATTANOOGA TN
37422-2784
US

V. Phone/Fax

Practice location:
  • Phone: 321-952-1818
  • Fax:
Mailing address:
  • Phone: 423-815-1600
  • Fax: 423-763-1118

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: KENNETH L SCOTT
Title or Position: PRESIDENT
Credential: D.O.
Phone: 423-815-1605