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General NPI Number Information
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NPI Number | 1730407420
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Entity Type | Organization
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Legal Business Name | PREMIUM MEDICAL CLINIC PA
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Dates
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Enumeration Date | 05/06/2010
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Last Update Date | 02/01/2012
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Provider Practice Location Address
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Address Line | 12211 REGENCY VILLAGE DR SUITE 2
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City | ORLANDO
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State | FL
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Zip | 32821-7813
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Country | US
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Telephone | 407-212-3060
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Fax | 877-644-7808
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Provider Business Mailing Address
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Address Line | 12211 REGENCY VILLAGE DR SUITE 2
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City | ORLANDO
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State | FL
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Zip | 32821-7813
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Country | US
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Telephone | 407-212-3060
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Fax | 877-644-7808
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Authorized Official
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Title or Position | PRESIDENT/OWNER
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Name | DR. SAFAA ABDEL-AL
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Credential | M.D.
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Telephone | 407-212-3060
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | ME97108
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License Number State | FL
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