MEDICARE: MID-FLORIDA RHEUMATOLOGY 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	207RR0500X	Rheumatology Physician

General Provider Information

NPI Number	:	1972069946
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MID-FLORIDA RHEUMATOLOGY LLC

Provider Business Mailing Address
First Line	:	1743 PARK CENTER DR STE 400
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32835-7621
Country	:	US
Telephone Number	:	386-668-4202
Fax Number	:	386-668-4207

Provider Business Practice Location Address
First Line	:	1743 PARK CENTER DR STE 400
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32835-7621
Country	:	US
Telephone Number	:	386-668-4202
Fax Number	:	386-668-4207

Authorized Official
Title or Position	:	MD
Name	:	KWABENA AYESU
Credential	:	MD
Telephone Number	:	386-668-4202

Provider Enumeration Date	:	02/14/2019
Last Update Date	:	04/29/2019

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