MEDICARE: FAMILY MEDICINE & CLINICAL RESEARCH OF CENTRAL FLORIDA 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	261QP2300X	Primary Care Clinic/Center	PA9102434	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	173000000X	OTHER	FL	PRIMARY TAXONOMY

General Provider Information

NPI Number	:	1730378241
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY MEDICINE & CLINICAL RESEARCH OF CENTRAL FLORIDA LLC

Provider Business Mailing Address
First Line	:	1603 S HIAWASSEE RD
Second Line	:	SUITE 115
City	:	ORLANDO
State	:	FL
Zip	:	32835-6438
Country	:	US
Telephone Number	:	407-299-6700
Fax Number	:	407-299-2265

Provider Business Practice Location Address
First Line	:	1603 S HIAWASSEE RD
Second Line	:	SUITE 115
City	:	ORLANDO
State	:	FL
Zip	:	32835-6438
Country	:	US
Telephone Number	:	407-299-6700
Fax Number	:	407-299-2265

Authorized Official
Title or Position	:	PRESIDENT / CEO
Name	:	MR. DENNIS GEORGE GAY II
Credential	:	PA-C
Telephone Number	:	407-451-1849

Provider Enumeration Date	:	10/21/2007
Last Update Date	:	07/24/2008

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