MEDICARE: COMMONS DRIVE FAMILY MEDICINE, LLC

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	ME76868	FL

General Provider Information

NPI Number	:	1689935926
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMMONS DRIVE FAMILY MEDICINE, LLC

Provider Business Mailing Address
First Line	:	PO BOX 635
Second Line	:
City	:	DESTIN
State	:	FL
Zip	:	32540-0635
Country	:	US
Telephone Number	:	850-650-2600
Fax Number	:	206-338-2314

Provider Business Practice Location Address
First Line	:	4012 COMMONS DR W STE 112
Second Line	:
City	:	DESTIN
State	:	FL
Zip	:	32541-8424
Country	:	US
Telephone Number	:	850-650-2600
Fax Number	:	206-338-2314

Authorized Official
Title or Position	:	SOLE MBR
Name	:	DR. ANDRE ABELLY
Credential	:	M.D.
Telephone Number	:	850-650-2600

Provider Enumeration Date	:	06/04/2012
Last Update Date	:	06/04/2012

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