Basic Information
| Provider Information | |||||||||
| NPI: | 1629060033 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FLORIDA HOSPITAL MEDICAL GROUP INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ORLANDO NEUROSURGERY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1605 W FAIRBANKS AVE | ||||||||
| Address2: | |||||||||
| City: | WINTER PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327894603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4079750200 | ||||||||
| FaxNumber: | 4709750209 | ||||||||
| Practice Location | |||||||||
| Address1: | 1605 W FAIRBANKS AVE | ||||||||
| Address2: | |||||||||
| City: | WINTER PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327894603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4079750200 | ||||||||
| FaxNumber: | 4709750209 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2005 | ||||||||
| LastUpdateDate: | 10/18/2012 | ||||||||
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| AuthorizedOfficialLastName: | STILTZ | ||||||||
| AuthorizedOfficialFirstName: | BRYAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4072002733 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 34958 | 01 | FL | BLUE CROSS/BLUE SHIELD | OTHER | 268791700 | 05 | FL | MEDICAID |