1295786069 NPI number — FAMILY INTERNAL MEDICINE, PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295786069 NPI number — FAMILY INTERNAL MEDICINE, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY INTERNAL MEDICINE, PA
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:
1295786069
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/20/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 940220
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MAITLAND
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32794-0220
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-384-1718
Provider Business Mailing Address Fax Number:
407-384-1806

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7824 LAKE UNDERHILL RD
Provider Second Line Business Practice Location Address:
SUITE H
Provider Business Practice Location Address City Name:
ORLANDO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32822-8201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-384-1718
Provider Business Practice Location Address Fax Number:
407-384-1806
Provider Enumeration Date:
05/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
REDDY
Authorized Official First Name:
RAM
Authorized Official Middle Name:
K
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
407-384-1718

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 999999999 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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