Healthcare Provider Details

I. General information

NPI: 1770570806
Provider Name (Legal Business Name): RURAL MEDICAL ASSOCIATES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2005
Last Update Date: 07/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 WEBSTER ST
WILDWOOD FL
34785-4036
US

IV. Provider business mailing address

605 LAMAR AVE
BROOKSVILLE FL
34601-3211
US

V. Phone/Fax

Practice location:
  • Phone: 352-748-6689
  • Fax: 352-748-6381
Mailing address:
  • Phone: 352-799-5411
  • Fax: 352-544-2713

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number5025
License Number StateFL

VIII. Authorized Official

Name: MR. CHARLES WILLIAM COSNER
Title or Position: V.P. OPERATIONS
Credential:
Phone: 352-799-5411