=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366957482
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VENTURE MEDICAL OF FLORIDA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/12/2017
-----------------------------------------------------
Last Update Date | 08/23/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 430 8TH AVE W
-----------------------------------------------------
City | PALMETTO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34221-5120
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-544-0366
-----------------------------------------------------
Fax | 941-212-6059
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7206 16TH AVE NW
-----------------------------------------------------
City | BRADENTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34209-1151
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | ALEXANDER N PETREAS
-----------------------------------------------------
Credential | PA
-----------------------------------------------------
Telephone | 941-400-7051
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QU0200X
-----------------------------------------------------
Taxonomy Name | Urgent Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------