Healthcare Provider Details

I. General information

NPI: 1548600869
Provider Name (Legal Business Name): PORT ORANGE GYNECOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2013
Last Update Date: 10/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 N SWALLOWTAIL DR ST 102B
PORT ORANGE FL
32129-6102
US

IV. Provider business mailing address

PO BOX 12051
BELFAST ME
04915-4011
US

V. Phone/Fax

Practice location:
  • Phone: 386-492-6929
  • Fax: 386-492-6930
Mailing address:
  • Phone: 386-492-6929
  • Fax: 386-492-6930

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License NumberME97528
License Number StateFL

VIII. Authorized Official

Name: PAULA M. FOUST
Title or Position: M.D. OWNER
Credential: M.D.
Phone: 386-492-6929