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General NPI Number Information
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NPI Number | 1336356492
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Entity Type | Organization
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Legal Business Name | THE FAMILY PHYSICIAN OF BVL
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Dates
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Enumeration Date | 05/17/2007
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Last Update Date | 04/27/2011
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Provider Practice Location Address
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Address Line | 3071 MICHIGAN AVE
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City | KISSIMMEE
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State | FL
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Zip | 34744-1501
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Country | US
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Telephone | 407-348-9111
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Fax | 407-348-9112
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Provider Business Mailing Address
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Address Line | 3071 MICHIGAN AVE
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City | KISSIMMEE
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State | FL
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Zip | 34744-1501
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Country | US
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Telephone | 407-348-9111
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Fax | 407-348-9112
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Authorized Official
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Title or Position | PHYSICAN
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Name | DR. FAUSTO RONALD BURGOS
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Credential | MD
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Telephone | 407-348-9111
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 173000000X
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Taxonomy Name | Legal Medicine
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License Number | ME62672
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License Number State | FL
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