MEDICARE: PEACE RIVER TROPICAL MEDICINE INC

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

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	:	1720126238
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEACE RIVER TROPICAL MEDICINE INC

Provider Business Mailing Address
First Line	:	PO BOX 510297
Second Line	:
City	:	PUNTA GORDA
State	:	FL
Zip	:	33951-0297
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	733 E OLYMPIA AVE
Second Line	:
City	:	PUNTA GORDA
State	:	FL
Zip	:	33950-3841
Country	:	US
Telephone Number	:	941-380-6022
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	EMIL ANTON DAMEFF
Credential	:	M.D.
Telephone Number	:	941-380-6022

Provider Enumeration Date	:	02/05/2007
Last Update Date	:	10/28/2013

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