Basic Information
| Provider Information | |||||||||
| NPI: | 1356005342 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VMD PRIMARY PROVIDERS CENTRAL FLORIDA PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 125 S CLARK ST STE 900 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606034043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7134612915 | ||||||||
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| Practice Location | |||||||||
| Address1: | 800 W BAY DR UNIT 1 | ||||||||
| Address2: | |||||||||
| City: | LARGO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337703222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4077988800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2021 | ||||||||
| LastUpdateDate: | 10/26/2021 | ||||||||
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| AuthorizedOfficialLastName: | LEE | ||||||||
| AuthorizedOfficialFirstName: | KRISTI | ||||||||
| AuthorizedOfficialMiddleName: | I | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7065134897 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | VMD PRIMARY PROVIDERS CENTRAL FLORIDA PLLC | ||||||||
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| NPICertificationDate: | 10/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.