MEDICARE: MY FAMILY 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	261QM1300X	Multi-Specialty Clinic/Center	ACN804	FL

General Provider Information

NPI Number	:	1255888160
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MY FAMILY MEDICAL GROUP LLC

Provider Business Mailing Address
First Line	:	4311 ANDERSON RD
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32812-7358
Country	:	US
Telephone Number	:	787-433-0055
Fax Number	:	787-931-7755

Provider Business Practice Location Address
First Line	:	4311 ANDERSON RD
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32812-7358
Country	:	US
Telephone Number	:	787-433-0055
Fax Number	:	787-931-7755

Authorized Official
Title or Position	:	CEO
Name	:	DR. CARLOS R CARDONA
Credential	:	M. D.
Telephone Number	:	787-433-0055

Provider Enumeration Date	:	09/08/2016
Last Update Date	:	09/08/2016

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