MEDICARE: FAMILY PRACTICE-ST CLOUD, 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	207Q00000X	Family Medicine Physician	ME0036943	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	34984	OTHER	FL	BLUE CROSS BLUE SHEILD
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1336189190
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY PRACTICE-ST CLOUD, INC.

Provider Business Mailing Address
First Line	:	3100 17TH ST
Second Line	:
City	:	SAINT CLOUD
State	:	FL
Zip	:	34769-6021
Country	:	US
Telephone Number	:	407-892-0009
Fax Number	:	407-892-3285

Provider Business Practice Location Address
First Line	:	3100 17TH ST
Second Line	:
City	:	SAINT CLOUD
State	:	FL
Zip	:	34769-6021
Country	:	US
Telephone Number	:	407-892-0009
Fax Number	:	407-892-3285

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JOHN FREDERICK WILKER
Credential	:	MD
Telephone Number	:	407-892-0009

Provider Enumeration Date	:	06/08/2006
Last Update Date	:	02/06/2023

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Directions to “FAMILY PRACTICE-ST CLOUD, INC. ” Practice Location

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