=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508009457
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FLORIDA INTERNAL MEDICINE GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/08/2009
-----------------------------------------------------
Last Update Date | 07/22/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 29 DOCTORS DRIVE
-----------------------------------------------------
City | PANAMA CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-872-0332
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 922
-----------------------------------------------------
City | PANAMA CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32402-0922
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-872-0332
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MOHAMED KASSEM
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 850-872-0332
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | ME91546
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------