=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821476375
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PREVENTIVE MEDICINE OF SARASOTA, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/15/2015
-----------------------------------------------------
Last Update Date | 05/15/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9114 TOWN CENTER PKWY
-----------------------------------------------------
City | LAKEWOOD RANCH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34202-5053
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-351-4949
-----------------------------------------------------
Fax | 941-351-3033
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1853 GROVE ST
-----------------------------------------------------
City | SARASOTA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34239-4509
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-366-3848
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JOSEPH BUBINAK
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 941-400-4965
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | ME29207
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------