Basic Information
| Provider Information | |||||||||
| NPI: | 1285662221 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FLORIDA PHYSICIANS MEDICAL GROUP INC | ||||||||
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| OtherOrganizationName: | FAMILY PRACTICE CENTER OF AVON PARK | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 538600 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328538600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4072002700 | ||||||||
| FaxNumber: | 4072004904 | ||||||||
| Practice Location | |||||||||
| Address1: | 1006 W PLEASANT ST | ||||||||
| Address2: | |||||||||
| City: | AVON PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338252966 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8634533121 | ||||||||
| FaxNumber: | 8634522823 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2006 | ||||||||
| LastUpdateDate: | 01/07/2008 | ||||||||
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| AuthorizedOfficialLastName: | STILTZ | ||||||||
| AuthorizedOfficialFirstName: | BRYAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4072002700 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 363AM0700X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 207Q00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.