MEDICARE: FLORIDA CLINICAL PRACTICE ASSOCIATION INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	208000000X	Pediatrics Physician
2	363A00000X	Physician Assistant
3	363L00000X	Nurse Practitioner
4	207Q00000X	Family Medicine Physician

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	:	1629138292
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FLORIDA CLINICAL PRACTICE ASSOCIATION INC

Provider Business Mailing Address
First Line	:	PO BOX 13833
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19101-3833
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	25827 SE HIGHWAY 19
Second Line	:
City	:	OLD TOWN
State	:	FL
Zip	:	32680-3997
Country	:	US
Telephone Number	:	352-265-7922
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE VICE PRESIDENT
Name	:	WILLIAM W THARP
Credential	:
Telephone Number	:	352-265-8017

Provider Enumeration Date	:	12/12/2006
Last Update Date	:	12/28/2015

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