=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972048536
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TLC MEDICAL GROUP,INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/05/2017
-----------------------------------------------------
Last Update Date | 01/11/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 537 NW LAKE WHITNEY PL UNIT 103-106
-----------------------------------------------------
City | PORT SAINT LUCIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34986-1620
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-877-8578
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1391 NW SAINT LUCIE WEST BLVD #216
-----------------------------------------------------
City | PORT SAINT LUCIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34986-2196
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | ANTHONY B LEWIS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 772-528-9074
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------