MEDICARE: PRIME HEALTH OF NORTH PORT 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	ME84648	FL

General Provider Information

NPI Number	:	1740228386
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRIME HEALTH OF NORTH PORT LLC

Provider Business Mailing Address
First Line	:	2975 BOBCAT VILLAGE CENTER RD
Second Line	:	SUITE 100
City	:	NORTH PORT
State	:	FL
Zip	:	34288-4600
Country	:	US
Telephone Number	:	941-423-9936
Fax Number	:	941-426-9794

Provider Business Practice Location Address
First Line	:	2975 BOBCAT VILLAGE CENTER RD
Second Line	:	SUITE 100
City	:	NORTH PORT
State	:	FL
Zip	:	34288-4600
Country	:	US
Telephone Number	:	941-423-9936
Fax Number	:	941-426-9794

Authorized Official
Title or Position	:	OWNER
Name	:	LEE GROSS
Credential	:	MD
Telephone Number	:	941-423-9936

Provider Enumeration Date	:	06/04/2006
Last Update Date	:	09/27/2011

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Directions to “PRIME HEALTH OF NORTH PORT LLC ” Practice Location

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