Basic Information
| Provider Information | |||||||||
| NPI: | 1013300912 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHYSICIANS HOUSECALL TEAM, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3616 HARDEN BLVD | ||||||||
| Address2: | #311 | ||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338035938 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8632682921 | ||||||||
| FaxNumber: | 8632682923 | ||||||||
| Practice Location | |||||||||
| Address1: | 1225 HAVENDALE BLVD NW | ||||||||
| Address2: | #338 | ||||||||
| City: | WINTER HAVEN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338811349 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8632682921 | ||||||||
| FaxNumber: | 8632682923 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2015 | ||||||||
| LastUpdateDate: | 04/16/2015 | ||||||||
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| AuthorizedOfficialLastName: | DEAN | ||||||||
| AuthorizedOfficialFirstName: | BYRON | ||||||||
| AuthorizedOfficialMiddleName: | RENARD | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4077196673 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | OS9203 | FL | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 245345600 | 05 | FL | MEDICAID |