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General NPI Number Information
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NPI Number | 1457523003
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Entity Type | Organization
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Legal Business Name | INSTITUTE OF INTERNAL MEDICINE P A
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Dates
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Enumeration Date | 03/24/2008
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Last Update Date | 09/15/2011
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Provider Practice Location Address
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Address Line | 1301 PLANTATION ISLAND DR S STE 402B
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City | ST AUGUSTINE
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State | FL
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Zip | 32080-3108
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Country | US
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Telephone | 904-460-0707
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Fax |
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Provider Business Mailing Address
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Address Line | 1301 PLANTATION ISLAND DR S STE 402-B
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City | ST AUGUSTINE
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State | FL
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Zip | 32080-3108
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Country | US
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Telephone | 904-460-0707
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | CARMEN C VIVERO
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Credential | MD
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Telephone | 904-460-0707
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RA0401X
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Taxonomy Name | Addiction Medicine (Internal Medicine) Physician
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License Number | ME76599
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | ME76599
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License Number State | FL
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