Healthcare Provider Details

I. General information

NPI: 1922192574
Provider Name (Legal Business Name): FAMILY MEDICAL CARE OF RIVERVIEW PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 01/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7229 US HIGHWAY 301 S
RIVERVIEW FL
33578-4346
US

IV. Provider business mailing address

7229 US HIGHWAY 301 S
RIVERVIEW FL
33578-4346
US

V. Phone/Fax

Practice location:
  • Phone: 813-677-8418
  • Fax: 813-677-8419
Mailing address:
  • Phone: 813-677-8418
  • Fax: 813-677-8419

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateFL

VIII. Authorized Official

Name: EDDIE G. LOUDERBACK
Title or Position: OFFICE ADMINISTRATOR
Credential: C.M.M.
Phone: 813-677-8418