Basic Information
| Provider Information | |||||||||
| NPI: | 1043753213 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MDVIP MEDICAL GROUP PA LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4950 COMMUNICATION AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | BOCA RATON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334313307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5619824300 | ||||||||
| FaxNumber: | 5619536617 | ||||||||
| Practice Location | |||||||||
| Address1: | 2300 COMPUTER RD | ||||||||
| Address2: | SUITE M69 | ||||||||
| City: | WILLOW GROVE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190901752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2153462821 | ||||||||
| FaxNumber: | 2153462823 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2016 | ||||||||
| LastUpdateDate: | 11/21/2016 | ||||||||
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| AuthorizedOfficialLastName: | KLEMES | ||||||||
| AuthorizedOfficialFirstName: | ANDREA | ||||||||
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| AuthorizedOfficialTitleorPosition: | SOLE MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 5619824300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MDVIP MEDICAL GROUP HOLDINGS LLC | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.