MEDICARE: NEMOU MEDICAL 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	208M00000X	Hospitalist Physician
2	207R00000X	Internal Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	ME 109018	OTHER	FL	MEDICAL LICENSE

General Provider Information

NPI Number	:	1043687767
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NEMOU MEDICAL LLC

Provider Business Mailing Address
First Line	:	231 RIVERSIDE DRIVE
Second Line	:	APT 2309
City	:	HOLLY HILL
State	:	FL
Zip	:	32117
Country	:	US
Telephone Number	:	330-774-3371
Fax Number	:

Provider Business Practice Location Address
First Line	:	231 RIVERSIDE DR UNIT 2309
Second Line	:
City	:	HOLLY HILL
State	:	FL
Zip	:	32117-4964
Country	:	US
Telephone Number	:	330-774-3371
Fax Number	:	888-959-3690

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. KHALIL NEMOU
Credential	:	M.D.
Telephone Number	:	386-898-9801

Provider Enumeration Date	:	08/28/2015
Last Update Date	:	05/19/2016

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Directions to “NEMOU MEDICAL LLC ” Practice Location

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