=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790189447
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHYSICIAN ASSOCIATES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/09/2014
-----------------------------------------------------
Last Update Date | 10/04/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7350 SAND LAKE COMMONS BLVD SUITE 1102
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32819-8040
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-355-7478
-----------------------------------------------------
Fax | 407-354-2431
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 235 N WESTMONTE DR
-----------------------------------------------------
City | ALTAMONTE SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32714-3345
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-262-5710
-----------------------------------------------------
Fax | 407-389-5312
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CONTRACTING/CREDENTIALING DIRECTOR
-----------------------------------------------------
Name | JENNIFER SAVAGE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 407-649-7412
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | ME87792
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------