MEDICARE: FAMILY HEALTH CENTER AT PORT ST JOHN 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	OS9694	FL

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	:	1851575377
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY HEALTH CENTER AT PORT ST JOHN LLC

Provider Business Mailing Address
First Line	:	3740 CURTIS BLVD
Second Line	:	SUITE 108
City	:	COCOA
State	:	FL
Zip	:	32927-3962
Country	:	US
Telephone Number	:	321-633-5500
Fax Number	:	321-633-5566

Provider Business Practice Location Address
First Line	:	3740 CURTIS BLVD
Second Line	:	SUITE 108
City	:	COCOA
State	:	FL
Zip	:	32927-3962
Country	:	US
Telephone Number	:	321-633-5500
Fax Number	:	321-633-5566

Authorized Official
Title or Position	:	PHYSICIAN/OWNER
Name	:	DR. JANIS G BLACK
Credential	:	D.O.
Telephone Number	:	321-633-5500

Provider Enumeration Date	:	12/19/2007
Last Update Date	:	12/03/2013

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