MEDICARE: FLORIDA MEDIAL PRACTICE PLAN

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

General Provider Information

NPI Number	:	1710685615
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FLORIDA MEDIAL PRACTICE PLAN

Provider Business Mailing Address
First Line	:	1115 W CALL ST STE 1120-F
Second Line	:
City	:	TALLAHASSEE
State	:	FL
Zip	:	32304-3556
Country	:	US
Telephone Number	:	850-644-9372
Fax Number	:

Provider Business Practice Location Address
First Line	:	2000 LEVY AVE STE 337
Second Line	:
City	:	TALLAHASSEE
State	:	FL
Zip	:	32310-5792
Country	:	US
Telephone Number	:	850-644-9372
Fax Number	:

Authorized Official
Title or Position	:	BILLING MANAGER
Name	:	JULIE HUBBARD
Credential	:
Telephone Number	:	850-644-1543

Provider Enumeration Date	:	02/20/2023
Last Update Date	:	02/20/2023

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Directions to “FLORIDA MEDIAL PRACTICE PLAN ” Practice Location

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