=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871633040
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMMUNITY PHYSICIANS OF NORTH PORT PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2007
-----------------------------------------------------
Last Update Date | 02/10/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14400 TAMIAMI TRL
-----------------------------------------------------
City | NORTH PORT
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34287-2703
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-423-5056
-----------------------------------------------------
Fax | 941-423-5068
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14400 TAMIAMI TRL
-----------------------------------------------------
City | NORTH PORT
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34287-2703
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-423-5056
-----------------------------------------------------
Fax | 941-423-5068
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | JAMIE S WHIDDEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 941-423-5053
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | OS7878
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | ME 0066832
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------