1902094725 NPI number — GFM FAMILY MEDICINE

Table of content: (NPI 1902094725)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902094725 NPI number — GFM FAMILY MEDICINE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GFM FAMILY MEDICINE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1902094725
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/14/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5575 S SEMORAN BLVD
Provider Second Line Business Mailing Address:
SUITE 23
Provider Business Mailing Address City Name:
ORLANDO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32822-1747
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-275-0080
Provider Business Mailing Address Fax Number:
407-275-8775

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5575 S SEMORAN BLVD
Provider Second Line Business Practice Location Address:
SUITE 23
Provider Business Practice Location Address City Name:
ORLANDO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32822-1747
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-275-0080
Provider Business Practice Location Address Fax Number:
407-275-8775
Provider Enumeration Date:
10/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
AMENDOLA
Authorized Official First Name:
EDWARD
Authorized Official Middle Name:
Authorized Official Title or Position:
BILLING MANAGER
Authorized Official Telephone Number:
407-275-0080

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 28143 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: BD4403161 . This is a "D.E.A. NUMBER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 51801387 . This is a "AETNA PROVIDER NUMBER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: ME61279 . This is a "FLORIDA STATE LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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