Basic Information
Provider Information | |||||||||
NPI: | 1679209183 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HEALTH FIRST MEDICAL GROUP, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3300 S FISKE BLVD | ||||||||
Address2: |   | ||||||||
City: | ROCKLEDGE | ||||||||
State: | FL | ||||||||
PostalCode: | 329554306 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3214345055 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 6525 3RD ST STE 302 | ||||||||
Address2: |   | ||||||||
City: | ROCKLEDGE | ||||||||
State: | FL | ||||||||
PostalCode: | 329555749 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3213615675 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/27/2022 | ||||||||
LastUpdateDate: | 07/27/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MORSE | ||||||||
AuthorizedOfficialFirstName: | LORA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VP PROFESSIONAL FEE SERVICES | ||||||||
AuthorizedOfficialTelephone: | 3214346116 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/27/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS0010X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 213ES0103X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
ID | Type | State | Issuer | Description | 008009063 | 05 | FL |   | MEDICAID |