Basic Information
| Provider Information | |||||||||
| NPI: | 1669768065 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ORLANDO PHYSICIAN SPECIALISTS LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WINTER PARK CANCER CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1561 W FAIRBANKS AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | WINTER PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327894678 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3212750333 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1561 W FAIRBANKS AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | WINTER PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327894678 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4074784920 | ||||||||
| FaxNumber: | 4074784921 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2011 | ||||||||
| LastUpdateDate: | 08/01/2016 | ||||||||
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| AuthorizedOfficialLastName: | WITTEN | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3212750333 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 004206300 | 05 | FL | MEDICAID | DS5207 | 01 | FL | RR MEDICARE | OTHER | 0027J | 01 | FL | BCBS | OTHER |