=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194175471
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHYSICIANS CHOICE GROUP, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/16/2016
-----------------------------------------------------
Last Update Date | 06/18/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5489 WILES RD SUITE 302
-----------------------------------------------------
City | COCONUT CREEK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33073-4220
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-448-4287
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5489 WILES RD SUITE 302
-----------------------------------------------------
City | COCONUT CREEK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33073-4220
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-448-4287
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. RAY WILSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 954-448-4287
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------