Healthcare Provider Details

I. General information

NPI: 1629990395
Provider Name (Legal Business Name): FWC PERINATAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2026
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3108 17TH STREET SUITE E
ST CLOUD FL
34769
US

IV. Provider business mailing address

PO BOX 818018
CLEVELAND OH
44181-8018
US

V. Phone/Fax

Practice location:
  • Phone: 405-662-2299
  • Fax: 407-566-2499
Mailing address:
  • Phone: 561-300-2410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: TAMMY WALKER
Title or Position: ENROLLMENT
Credential:
Phone: 561-300-2410