MEDICARE: DOCTORS WELLNES CLINIC

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	363AM0700X	Medical Physician Assistant	PA9101571	FL

General Provider Information

NPI Number	:	1861574634
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DOCTORS WELLNES CLINIC

Provider Business Mailing Address
First Line	:	13133 66TH ST
Second Line	:
City	:	LARGO
State	:	FL
Zip	:	33773-1812
Country	:	US
Telephone Number	:	727-330-7743
Fax Number	:	727-330-7745

Provider Business Practice Location Address
First Line	:	13133 66TH ST
Second Line	:
City	:	LARGO
State	:	FL
Zip	:	33773-1812
Country	:	US
Telephone Number	:	727-330-7743
Fax Number	:	727-330-7745

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MIKE PAUL LINKOUS
Credential	:	PA-C
Telephone Number	:	727-330-7743

Provider Enumeration Date	:	10/20/2006
Last Update Date	:	06/21/2010

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Practice Location Address:

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1225017833 — DR. CARRIE L SHULMAN MD
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1528003043 — DR. DMITRY A. GREBENEV M.D.
Practice Location Address:

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1558452664 — JEANNETTE F LEVY A.P.R.N.
Practice Location Address:

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1477643617 — MICHAEL PAUL LINKOUS PHYSICAN ASSISTANT
Practice Location Address:

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