1366816514 NPI number — FAMILY MEDICINE SPECIALISTS, S.C.

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 1366816514 NPI number — FAMILY MEDICINE SPECIALISTS, S.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY MEDICINE SPECIALISTS, S.C.
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:
6
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:
1366816514
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/25/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
311 PARK PLACE BLVD
Provider Second Line Business Mailing Address:
5TH FLOOR
Provider Business Mailing Address City Name:
CLEARWATER
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33759-4904
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-755-0693
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
431 W LIBERTY STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAUCONDA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60084
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-508-5897
Provider Business Practice Location Address Fax Number:
847-526-2017
Provider Enumeration Date:
11/25/2015

Additional Information

Authorized Official

Authorized Official Last Name:
WORTHEN
Authorized Official First Name:
JASMINE
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING SPECIALIST
Authorized Official Telephone Number:
727-755-0693

Provider Taxonomy Codes

  • Taxonomy code: 332900000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 036083207 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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