=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083948392
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUN STATE PHYSICIANS SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2009
-----------------------------------------------------
Last Update Date | 09/21/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | SPRING HILLS AT HUNTER'S CREEK TOWN CENTER BLVD
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32837
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-251-8088
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 451624
-----------------------------------------------------
City | KISSIMMEE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34745-1624
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-928-1880
-----------------------------------------------------
Fax | 407-201-2345
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. FELIPE COLLAZO-PAGAN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 407-928-5766
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QG0300X
-----------------------------------------------------
Taxonomy Name | Geriatric Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------