=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366647661
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRIMARY CARE SPECIALISTS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2007
-----------------------------------------------------
Last Update Date | 09/06/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1800 MERCY DR STE 104
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32808-5646
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-523-3523
-----------------------------------------------------
Fax | 407-523-3588
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1800 MERCY DR STE 104
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32808-5646
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-523-3523
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARTNER
-----------------------------------------------------
Name | GERALD J KIVETT
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 407-275-9014
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | ME63176
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------