Healthcare Provider Details

I. General information

NPI: 1134336209
Provider Name (Legal Business Name): ANGLIN MEDICAL PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 01/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13045 SUMMERFIELD SQUARE DR
RIVERVIEW FL
33578-7402
US

IV. Provider business mailing address

13045 SUMMERFIELD SQUARE DR
RIVERVIEW FL
33578-7402
US

V. Phone/Fax

Practice location:
  • Phone: 813-672-1385
  • Fax: 813-672-8904
Mailing address:
  • Phone: 813-672-1385
  • Fax: 813-672-8904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberME91647
License Number StateFL

VIII. Authorized Official

Name: DR. MICKEL WRAY ANGLIN
Title or Position: PRESIDENT
Credential: MD
Phone: 813-672-1385