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General NPI Number Information
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NPI Number | 1386940013
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Entity Type | Organization
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Legal Business Name | TUI FAMILY MEDICINE PL
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Dates
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Enumeration Date | 01/27/2011
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Last Update Date | 10/12/2011
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Provider Practice Location Address
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Address Line | 4554 S CLYDE MORRIS BLVD SUITE 2
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City | PORT ORANGE
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State | FL
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Zip | 32129-5403
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Country | US
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Telephone | 386-304-2990
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 290035
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City | PORT ORANGE
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State | FL
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Zip | 32129-0035
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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 | MANAGING MEMBER
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Name | ANUNPORN SRISAWAT
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Credential | MD
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Telephone | 386-304-2990
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | ME 95967
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License Number State | FL
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