Healthcare Provider Details

I. General information

NPI: 1083481824
Provider Name (Legal Business Name): MEDICAL PSYCHIATRIC PROVIDERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2023
Last Update Date: 06/21/2024
Certification Date: 06/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 WATERFIELD DR
GARNER NC
27529-7727
US

IV. Provider business mailing address

4300 W LAKE MARY BLVD STE 1010-357
LAKE MARY FL
32746-2060
US

V. Phone/Fax

Practice location:
  • Phone: 407-732-7957
  • Fax:
Mailing address:
  • Phone: 407-732-7910
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: ERIC MOORE
Title or Position: OWNER
Credential: MD
Phone: 407-732-7957