Healthcare Provider Details

I. General information

NPI: 1275683682
Provider Name (Legal Business Name): NATURE COAST MEDICAL GROUP PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 07/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 SW 7TH ST
WILLISTON FL
32696-2404
US

IV. Provider business mailing address

130 SW 7TH ST
WILLISTON FL
32696-2404
US

V. Phone/Fax

Practice location:
  • Phone: 352-528-5801
  • Fax: 352-528-6019
Mailing address:
  • Phone: 352-528-5801
  • Fax: 352-528-6019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME0011887
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberOS0005395
License Number StateFL

VIII. Authorized Official

Name: DR. DONALD L MCCOY
Title or Position: PRESIDENT
Credential: D.O.
Phone: 352-528-5801