MEDICARE: TWIN CITIES PRIMARY CARE, 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	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1184662835
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TWIN CITIES PRIMARY CARE, LLC

Provider Business Mailing Address
First Line	:	479 HIGHWAY 20 E
Second Line	:
City	:	FREEPORT
State	:	FL
Zip	:	32439-3931
Country	:	US
Telephone Number	:	850-865-4121
Fax Number	:	850-865-2344

Provider Business Practice Location Address
First Line	:	479 HIGHWAY 20 E
Second Line	:
City	:	FREEPORT
State	:	FL
Zip	:	32439-3931
Country	:	US
Telephone Number	:	850-865-4121
Fax Number	:	850-865-2344

Authorized Official
Title or Position	:	AREA PRACTICE MANAGER
Name	:	MARY COSNER
Credential	:
Telephone Number	:	850-865-4121

Provider Enumeration Date	:	06/03/2006
Last Update Date	:	09/28/2007

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