=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629603436
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ONEMED FLORIDA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/12/2020
-----------------------------------------------------
Last Update Date | 04/06/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10129 CLEAR VISTA ST
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32832-7164
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 833-663-6331
-----------------------------------------------------
Fax | 833-673-0418
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10129 CLEAR VISTA ST
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32832-7164
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 833-663-6331
-----------------------------------------------------
Fax | 833-673-0418
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MD
-----------------------------------------------------
Name | REYNALD LAMARRE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 833-663-6331
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0805X
-----------------------------------------------------
Taxonomy Name | Geriatric Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------