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General NPI Number Information
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NPI Number | 1326196924
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Entity Type | Organization
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Legal Business Name | FIDELITY MEDICAL SERVICES PLC DBA MID-TOWN CENTER FOR HEALTH
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Dates
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Enumeration Date | 01/08/2007
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 701 OHIO AVE S
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City | LIVE OAK
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State | FL
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Zip | 32064-3816
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Country | US
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Telephone | 386-330-5248
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Fax |
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Provider Business Mailing Address
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Address Line | 701 OHIO AVE S
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City | LIVE OAK
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State | FL
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Zip | 32064-3816
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PARTNER
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Name | RICHARD WILLIS
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Credential |
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Telephone | 904-421-2119
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State | FL
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