Healthcare Provider Details

I. General information

NPI: 1093324832
Provider Name (Legal Business Name): VMD PRIMARY PROVIDERS WEST CENTRAL FLORIDA, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2020
Last Update Date: 07/28/2020
Certification Date: 07/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 S CLARK ST STE 900
CHICAGO IL
60603-4043
US

IV. Provider business mailing address

125 S CLARK ST STE 900
CHICAGO IL
60603-4043
US

V. Phone/Fax

Practice location:
  • Phone: 346-980-2701
  • Fax: 713-932-0437
Mailing address:
  • Phone: 346-980-2701
  • Fax: 713-932-0437

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: KRISTI I LEE
Title or Position: DIRECTOR
Credential: CMPE
Phone: 706-513-4897