Basic Information
| Provider Information | |||||||||
| NPI: | 1609911825 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OSCEOLA OB-GYN PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1160 CYPRESS GLEN CIR | ||||||||
| Address2: | |||||||||
| City: | KISSIMMEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347417560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4075181074 | ||||||||
| FaxNumber: | 4075189056 | ||||||||
| Practice Location | |||||||||
| Address1: | 1160 CYPRESS GLEN CIR | ||||||||
| Address2: | |||||||||
| City: | KISSIMMEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347417560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4075181074 | ||||||||
| FaxNumber: | 4075189056 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2007 | ||||||||
| LastUpdateDate: | 02/18/2014 | ||||||||
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| AuthorizedOfficialLastName: | DENARDIS | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | DO | ||||||||
| AuthorizedOfficialTelephone: | 4075181074 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 004198400 | 05 | FL | MEDICAID |