Basic Information
| Provider Information | |||||||||
| NPI: | 1629147228 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTERNAL MEDICINE AND PEDIATRICS ASSOCIATESOF TALLAHASSEE INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1965 CAPITAL CIR NE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | TALLAHASSEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323088401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8506562006 | ||||||||
| FaxNumber: | 8506562820 | ||||||||
| Practice Location | |||||||||
| Address1: | 1965 CAPITAL CIR NE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | TALLAHASSEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323088401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8506562006 | ||||||||
| FaxNumber: | 8506562820 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2006 | ||||||||
| LastUpdateDate: | 10/10/2016 | ||||||||
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| AuthorizedOfficialLastName: | MIGNON | ||||||||
| AuthorizedOfficialFirstName: | YVETTE | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8506562006 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 266400300 | 05 | FL | MEDICAID |