=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124412671
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ENTERPRISE INTERNAL MEDICINE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/23/2015
-----------------------------------------------------
Last Update Date | 03/23/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1507 PARK CENTER DR SUITE 1A
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32835-5795
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-808-8763
-----------------------------------------------------
Fax | 407-286-4167
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1507 PARK CENTER DR SUITE 1A
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32835-5795
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax | 407-286-4167
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. PHYLLIS A GERBER
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 407-808-8763
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | ME 66305
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------