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General NPI Number Information
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NPI Number | 1366816514
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Entity Type | Organization
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Legal Business Name | FAMILY MEDICINE SPECIALISTS, S.C.
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Dates
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Enumeration Date | 11/25/2015
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Last Update Date | 11/25/2015
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Provider Practice Location Address
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Address Line | 431 W LIBERTY STREET
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City | WAUCONDA
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State | IL
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Zip | 60084
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Country | US
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Telephone | 847-508-5897
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Fax | 847-526-2017
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Provider Business Mailing Address
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Address Line | 311 PARK PLACE BLVD 5TH FLOOR
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City | CLEARWATER
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State | FL
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Zip | 33759-4904
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Country | US
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Telephone | 727-755-0693
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Fax |
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Authorized Official
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Title or Position | CREDENTIALING SPECIALIST
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Name | JASMINE WORTHEN
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Credential |
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Telephone | 727-755-0693
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332900000X
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Taxonomy Name | Non-Pharmacy Dispensing Site
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License Number |
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License Number State |
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