Healthcare Provider Details

I. General information

NPI: 1801014253
Provider Name (Legal Business Name): BEACON HEAD AND NECK CLINIC, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 07/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 MEDICAL BLVD STE 100
SPRING HILL FL
34609-0221
US

IV. Provider business mailing address

PO BOX 917584
ORLANDO FL
32891-7584
US

V. Phone/Fax

Practice location:
  • Phone: 352-688-9282
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number85915
License Number StateFL

VIII. Authorized Official

Name: TED W BROWN
Title or Position: PRESIDENT
Credential:
Phone: 352-688-9282