Healthcare Provider Details

I. General information

NPI: 1245289578
Provider Name (Legal Business Name): ST CLOUD PHYSICIAN MANAGEMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 07/02/2020
Certification Date: 07/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 BUDINGER AVE SUITE D
SAINT CLOUD FL
34769-6008
US

IV. Provider business mailing address

52 W UNDERWOOD ST
ORLANDO FL
32806-1110
US

V. Phone/Fax

Practice location:
  • Phone: 407-892-3387
  • Fax: 407-892-7297
Mailing address:
  • Phone: 321-841-2452
  • Fax: 321-841-4076

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: ANGELINA CEDENO
Title or Position: MANAGER
Credential:
Phone: 407-481-7174