MEDICARE: FIDELITY PREMIER GROUP INC

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	363LF0000X	Family Nurse Practitioner

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

General Provider Information

NPI Number	:	1205562998
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FIDELITY PREMIER GROUP INC

Provider Business Mailing Address
First Line	:	11406 N DALE MABRY HWY STE 105
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33618-3879
Country	:	US
Telephone Number	:	813-438-4338
Fax Number	:	813-438-4968

Provider Business Practice Location Address
First Line	:	11406 N DALE MABRY HWY STE 105
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33618-3879
Country	:	US
Telephone Number	:	813-438-4338
Fax Number	:	813-438-4968

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL
Name	:	MR. FREDDY DURAN
Credential	:
Telephone Number	:	813-438-4338

Provider Enumeration Date	:	07/26/2022
Last Update Date	:	07/26/2022

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Directions to “FIDELITY PREMIER GROUP INC ” Practice Location

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