Basic Information
| Provider Information | |||||||||
| NPI: | 1538318589 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OSLER MEDICAL INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 930 S HARBOR CITY BLVD | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329011963 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217255050 | ||||||||
| FaxNumber: | 3217259100 | ||||||||
| Practice Location | |||||||||
| Address1: | 8057 SPYGLASS HILL RD | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329408565 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3214353500 | ||||||||
| FaxNumber: | 3214353501 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2008 | ||||||||
| LastUpdateDate: | 09/15/2008 | ||||||||
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| AuthorizedOfficialLastName: | BRITT | ||||||||
| AuthorizedOfficialFirstName: | LAURIE | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 3217255050 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | OSLER MEDICAL INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 256740718 | 05 | FL | MEDICAID |