MEDICARE: OLYMPIA MEDICAL GROUP, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	HCC11921	OTHER	FL	CLINIC LICENSE
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1013473495
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OLYMPIA MEDICAL GROUP, LLC

Provider Business Mailing Address
First Line	:	2306 NORTH BLVD W STE C
Second Line	:
City	:	DAVENPORT
State	:	FL
Zip	:	33837-8976
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2306 NORTH BLVD W STE C
Second Line	:
City	:	DAVENPORT
State	:	FL
Zip	:	33837-8976
Country	:	US
Telephone Number	:	863-547-9200
Fax Number	:

Authorized Official
Title or Position	:	MANAGING PARTNER
Name	:	BALA KODE
Credential	:
Telephone Number	:	863-547-9200

Provider Enumeration Date	:	02/11/2019
Last Update Date	:	12/22/2023

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