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General NPI Number Information
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NPI Number | 1417132465
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Entity Type | Organization
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Legal Business Name | MULBERRY MEDICAL GROUP PA
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Dates
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Enumeration Date | 01/08/2008
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Last Update Date | 08/23/2010
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Provider Practice Location Address
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Address Line | 8489 SE 165TH MULBERRY LN
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City | THE VILLAGES
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State | FL
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Zip | 32162-5847
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Country | US
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Telephone | 352-259-7900
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Fax | 352-259-7966
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Provider Business Mailing Address
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Address Line | PO BOX 587
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City | OXFORD
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State | FL
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Zip | 34484-0587
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Country | US
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Telephone | 352-259-7900
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Fax | 352-259-7966
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. GUILLERMO B AVECILLA
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Credential | MD
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Telephone | 352-259-7900
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | ME80865
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License Number State | FL
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