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General NPI Number Information
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NPI Number | 1730428020
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Entity Type | Organization
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Legal Business Name | PRIME OB/GYN P.A.
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Dates
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Enumeration Date | 02/06/2013
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Last Update Date | 02/06/2013
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Provider Practice Location Address
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Address Line | 1111 S ORANGE AVE FOURTH FLOOR
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City | ORLANDO
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State | FL
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Zip | 32806-1236
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Country | US
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Telephone | 407-205-7646
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Fax | 407-264-7774
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Provider Business Mailing Address
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Address Line | 773 TERRA PL
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City | MAITLAND
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State | FL
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Zip | 32751-4583
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Country | US
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Telephone | 407-205-7646
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Fax | 407-264-7774
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Authorized Official
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Title or Position | OWNER/PARTNER
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Name | DR. MATTHEW R MERVIS
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Credential | M.D.
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Telephone | 407-205-7646
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number |
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License Number State |
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