Healthcare Provider Details

I. General information

NPI: 1316192867
Provider Name (Legal Business Name): MARINER PRIMECARE MEDICAL CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/25/2008
Last Update Date: 11/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7056 MARINER BLVD
SPRING HILL FL
34609-1000
US

IV. Provider business mailing address

7056 MARINER BLVD
SPRING HILL FL
34609-1000
US

V. Phone/Fax

Practice location:
  • Phone: 352-597-5557
  • Fax: 352-597-0552
Mailing address:
  • Phone: 352-597-5557
  • Fax: 352-597-0552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberME83175
License Number StateFL

VIII. Authorized Official

Name: MR. MARTIN REVELLO
Title or Position: PRESIDENT
Credential: MPH
Phone: 813-514-6750