Basic Information
| Provider Information | |||||||||
| NPI: | 1609142553 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHYSICIAN ASSOCIATES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 235 N WESTMONTE DR | ||||||||
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| City: | ALTAMONTE SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327143345 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 12780 WATERFORD LAKES PKWY | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328284500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4073841053 | ||||||||
| FaxNumber: | 4072778168 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2012 | ||||||||
| LastUpdateDate: | 10/04/2017 | ||||||||
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| AuthorizedOfficialLastName: | BUHRING | ||||||||
| AuthorizedOfficialFirstName: | DENNIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4072625715 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 062757700 | 05 | FL | MEDICAID |