Basic Information
| Provider Information | |||||||||
| NPI: | 1649484809 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PULMONARY DISEASE SPECIALISTS, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1121 N CENTRAL AVE | ||||||||
| Address2: | SUITE B | ||||||||
| City: | KISSIMMEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347414405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4079331221 | ||||||||
| FaxNumber: | 4079331102 | ||||||||
| Practice Location | |||||||||
| Address1: | 1121 N CENTRAL AVE | ||||||||
| Address2: | SUITE B | ||||||||
| City: | KISSIMMEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347414405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4079331221 | ||||||||
| FaxNumber: | 4079331132 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2007 | ||||||||
| LastUpdateDate: | 03/18/2015 | ||||||||
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| AuthorizedOfficialLastName: | O'BRIEN | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4079331221 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 255536100 | 05 | FL | MEDICAID |