=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669548392
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WEIRSDALE FAMILY HEALTH CENTER INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/27/2006
-----------------------------------------------------
Last Update Date | 07/03/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16400 S HIGHWAY 25
-----------------------------------------------------
City | WEIRSDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32195-0008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-821-9797
-----------------------------------------------------
Fax | 352-821-0553
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16400 S HIGHWAY 25
-----------------------------------------------------
City | WEIRSDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32195-2442
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-821-9797
-----------------------------------------------------
Fax | 352-821-0553
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | DHARTI BISHT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 352-821-9797
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 261QR1300X
-----------------------------------------------------
Taxonomy Name | Rural Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------