Healthcare Provider Details

I. General information

NPI: 1265608012
Provider Name (Legal Business Name): MID-FLORIDA PHYSICIAN SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2008
Last Update Date: 07/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 AVENUE F NE
WINTER HAVEN FL
33881-4131
US

IV. Provider business mailing address

200 AVENUE F NE
WINTER HAVEN FL
33881-4131
US

V. Phone/Fax

Practice location:
  • Phone: 863-297-1899
  • Fax: 863-297-1867
Mailing address:
  • Phone: 863-297-1899
  • Fax: 863-297-1867

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: DAVE MACDOUGALL
Title or Position: CFO
Credential:
Phone: 863-297-1899