MEDICARE: KINGS BAY FAMILY CARE PA

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	OS7801	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DS4782	OTHER	FL	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	46431	OTHER	FL	BCBS

General Provider Information

NPI Number	:	1649218694
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KINGS BAY FAMILY CARE PA

Provider Business Mailing Address
First Line	:	14690 SPRING HILL DR
Second Line	:	SUITE 101
City	:	SPRING HILL
State	:	FL
Zip	:	34609-8102
Country	:	US
Telephone Number	:	352-795-2273
Fax Number	:	352-795-2296

Provider Business Practice Location Address
First Line	:	9030 W FORT ISLAND TRL
Second Line	:	SUITE 1
City	:	CRYSTAL RIVER
State	:	FL
Zip	:	34429-2412
Country	:	US
Telephone Number	:	352-795-2273
Fax Number	:	352-795-2296

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MICHAEL B MUELLER
Credential	:	D.O.
Telephone Number	:	352-795-2273

Provider Enumeration Date	:	06/03/2006
Last Update Date	:	08/10/2012

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Directions to “KINGS BAY FAMILY CARE PA ” Practice Location

Language	Start Address	Practice Location

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