MEDICARE: MYRTHO MOMPOINT-BRANCH MD 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	2084P0800X	Psychiatry Physician	ME73432	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	46298	OTHER	FL	BCBS

General Provider Information

NPI Number	:	1689686412
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MYRTHO MOMPOINT-BRANCH MD PA

Provider Business Mailing Address
First Line	:	2500 DISCOVERY DR
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32826-3709
Country	:	US
Telephone Number	:	407-275-2203
Fax Number	:	407-282-7012

Provider Business Practice Location Address
First Line	:	2500 DISCOVERY DR
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32826-3709
Country	:	US
Telephone Number	:	407-275-2203
Fax Number	:	407-282-7012

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MYRTHO MOMPOINT-BRANCH
Credential	:	MD
Telephone Number	:	407-275-2203

Provider Enumeration Date	:	08/12/2006
Last Update Date	:	08/22/2020

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