Basic Information
| Provider Information | |||||||||
| NPI: | 1548447535 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST LUCIE MEDICAL SPECIALISTS LLC | ||||||||
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| OtherOrganizationName: | HEART AND FAMILY HEALTH INSTITUTE OF PORT ST. LUCIE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3 MARYLAND FARMS | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370275005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8006613365 | ||||||||
| FaxNumber: | 8666894661 | ||||||||
| Practice Location | |||||||||
| Address1: | 1700 SE HILLMOOR DR | ||||||||
| Address2: | |||||||||
| City: | PORT ST LUCIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349527539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7723359600 | ||||||||
| FaxNumber: | 7723359699 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2008 | ||||||||
| LastUpdateDate: | 03/04/2011 | ||||||||
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| AuthorizedOfficialLastName: | DUNCAN | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP | ||||||||
| AuthorizedOfficialTelephone: | 9547675716 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RE0101X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | 207RG0100X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RR0500X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 6458380001 | 01 | FL | MEDICARE DME | OTHER |