Healthcare Provider Details

I. General information

NPI: 1457523003
Provider Name (Legal Business Name): INSTITUTE OF INTERNAL MEDICINE P A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2008
Last Update Date: 09/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 PLANTATION ISLAND DR S STE 402B
ST AUGUSTINE FL
32080-3108
US

IV. Provider business mailing address

1301 PLANTATION ISLAND DR S STE 402-B
ST AUGUSTINE FL
32080-3108
US

V. Phone/Fax

Practice location:
  • Phone: 904-460-0707
  • Fax:
Mailing address:
  • Phone: 904-460-0707
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License NumberME76599
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME76599
License Number StateFL

VIII. Authorized Official

Name: CARMEN C VIVERO
Title or Position: PRESIDENT
Credential: MD
Phone: 904-460-0707