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NPI Code Detail

MEDICARE: ISLAND DIRECT PRIMARY CARE LLC

MEDICARE: ISLAND DIRECT PRIMARY CARE 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
1261QP2300XPrimary Care Clinic/Center

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1811463961
Entity Type Code : Organization
Provider Name (Legal Business Name) : ISLAND DIRECT PRIMARY CARE LLC
Provider Business Mailing Address
First Line : 210 HICKORY AVE
Second Line :
City : MERRITT ISLAND
State : FL
Zip : 32953-4368
Country : US
Telephone Number : 321-506-2540
Fax Number :
Provider Business Practice Location Address
First Line : 390 N COURTENAY PKWY
Second Line :
City : MERRITT ISLAND
State : FL
Zip : 32953-3456
Country : US
Telephone Number : 321-506-2540
Fax Number :
Authorized Official
Title or Position : PRESIDENT
Name : DR. JOHN WESLEY ROTHWELL III
Credential : DNP
Telephone Number : 321-506-2540
Provider Enumeration Date : 10/16/2018
Last Update Date : 03/27/2022

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