Basic Information
| Provider Information | |||||||||
| NPI: | 1760962005 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SICKNWELL MEDICAL GROUP, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2066 | ||||||||
| Address2: | |||||||||
| City: | LECANTO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 344602066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3525630931 | ||||||||
| FaxNumber: | 3525630935 | ||||||||
| Practice Location | |||||||||
| Address1: | 6405 W GULF TO LAKE HWY | ||||||||
| Address2: | |||||||||
| City: | CRYSTAL RIVER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 344299354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3525276888 | ||||||||
| FaxNumber: | 3525278818 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2018 | ||||||||
| LastUpdateDate: | 08/16/2018 | ||||||||
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| AuthorizedOfficialLastName: | ST MARTIN | ||||||||
| AuthorizedOfficialFirstName: | DACELIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR / OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3525630935 | ||||||||
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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 | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.