Basic Information
| Provider Information | |||||||||
| NPI: | 1689873028 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAMILYCARE OF WESLEY CHAPEL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1942 HIGHLAND OAKS BLVD | ||||||||
| Address2: | STE A | ||||||||
| City: | LUTZ | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139483838 | ||||||||
| FaxNumber: | 8139490629 | ||||||||
| Practice Location | |||||||||
| Address1: | 5251 VILLAGE MARKET | ||||||||
| Address2: | |||||||||
| City: | WESLEY CHAPEL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139916000 | ||||||||
| FaxNumber: | 8139730605 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2007 | ||||||||
| LastUpdateDate: | 07/16/2007 | ||||||||
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| AuthorizedOfficialLastName: | ROSEQUIST | ||||||||
| AuthorizedOfficialFirstName: | LINDA | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 8139483838 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 53682 | 01 | FL | MEDICARE | OTHER | 02510 | 01 | FL | MEDICARE | OTHER |