Basic Information
| Provider Information | |||||||||
| NPI: | 1235422775 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MD2U FLORIDA LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7219 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402570219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5024161851 | ||||||||
| FaxNumber: | 5024161857 | ||||||||
| Practice Location | |||||||||
| Address1: | 10151 DEERWOOD PARK BLVD | ||||||||
| Address2: | 200-250 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322560566 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5023279100 | ||||||||
| FaxNumber: | 5027423767 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2011 | ||||||||
| LastUpdateDate: | 09/25/2012 | ||||||||
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| AuthorizedOfficialLastName: | LATTA | ||||||||
| AuthorizedOfficialFirstName: | GREGORY | ||||||||
| AuthorizedOfficialMiddleName: | D. | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO/CIO | ||||||||
| AuthorizedOfficialTelephone: | 5024161851 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MD2U MANAGEMENT LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LG0600X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
ID Information
| ID | Type | State | Issuer | Description | 10D2045820 | 01 | FL | CLIA - CERTIFICATE OF WAIVER | OTHER |