MEDICARE: DR. JAMES S PENDERGRAFT IV MD

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	207V00000X	Obstetrics & Gynecology Physician	ME5907	FL

General Provider Information

NPI Number	:	1194956318
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JAMES S PENDERGRAFT IV MD

Provider Business Mailing Address
First Line	:	1103 LUCERNE TER
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32806-1016
Country	:	US
Telephone Number	:	407-245-7999
Fax Number	:

Provider Business Practice Location Address
First Line	:	1103 LUCERNE TER
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32806-1016
Country	:	US
Telephone Number	:	407-245-7999
Fax Number	:	407-650-9456

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/05/2009
Last Update Date	:	08/05/2009

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