=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043551468
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ID CONSULTS AND SERVICES, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/11/2013
-----------------------------------------------------
Last Update Date | 10/17/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3142 NORTHSIDE DR SUITE 101
-----------------------------------------------------
City | KEY WEST
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33040-8012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-615-3300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3142 NORTHSIDE DR SUITE 101
-----------------------------------------------------
City | KEY WEST
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33040-8012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-615-3300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BUSINESS MANAGER
-----------------------------------------------------
Name | MR. DARRYL WALLACE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 770-977-5056
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RI0200X
-----------------------------------------------------
Taxonomy Name | Infectious Disease Physician
-----------------------------------------------------
License Number | ME 114239
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------