MEDICARE: TUI FAMILY MEDICINE PL

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	261Q00000X	Clinic/Center	ME 95967	FL

General Provider Information

NPI Number	:	1386940013
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TUI FAMILY MEDICINE PL

Provider Business Mailing Address
First Line	:	PO BOX 290035
Second Line	:
City	:	PORT ORANGE
State	:	FL
Zip	:	32129-0035
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4554 S CLYDE MORRIS BLVD
Second Line	:	SUITE 2
City	:	PORT ORANGE
State	:	FL
Zip	:	32129-5403
Country	:	US
Telephone Number	:	386-304-2990
Fax Number	:

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	ANUNPORN SRISAWAT
Credential	:	MD
Telephone Number	:	386-304-2990

Provider Enumeration Date	:	01/27/2011
Last Update Date	:	10/12/2011

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Directions to “TUI FAMILY MEDICINE PL ” Practice Location

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