=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215403936
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTRAL FLORIDA RHEUMATOLOGY CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/19/2018
-----------------------------------------------------
Last Update Date | 10/19/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 131 WEBB DR
-----------------------------------------------------
City | DAVENPORT
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33837-3921
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-660-4747
-----------------------------------------------------
Fax | 863-686-3482
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6439 HIGHLANDS IN THE WOODS ST
-----------------------------------------------------
City | LAKELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33813-3815
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 939-717-1265
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING SUPERVISOR
-----------------------------------------------------
Name | TAMMY BOEHRINGER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 863-514-8441
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RR0500X
-----------------------------------------------------
Taxonomy Name | Rheumatology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------