Basic Information
| Provider Information | |||||||||
| NPI: | 1245596964 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FLORIDA ID CARE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14192 METROPOLIS AVE | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339124331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2392458223 | ||||||||
| FaxNumber: | 2392449481 | ||||||||
| Practice Location | |||||||||
| Address1: | 3540 STUART CT | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339017737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6093504757 | ||||||||
| FaxNumber: | 2392449481 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2012 | ||||||||
| LastUpdateDate: | 04/13/2016 | ||||||||
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| AuthorizedOfficialLastName: | RAMAN | ||||||||
| AuthorizedOfficialFirstName: | SIVAKUMAR | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2392458223 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | ME100391 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
No ID Information.