=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306930540
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL R GEBAUER MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2006
-----------------------------------------------------
Last Update Date | 12/15/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3191 E SEMORAN BLVD
-----------------------------------------------------
City | APOPKA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32703-5943
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-788-6500
-----------------------------------------------------
Fax | 407-869-9400
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 917 RINEHART RD STE 1051
-----------------------------------------------------
City | LAKE MARY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32746-4853
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-788-6500
-----------------------------------------------------
Fax | 407-869-9400
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | ME0026923
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------