Basic Information
| Provider Information | |||||||||
| NPI: | 1841841830 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ALLIANCE OBSTETRICS AND GYNECOLOGY GROUP, LLC | ||||||||
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| OtherOrganizationName: | ALLIANCE OBSTETRICS AND GYNECOLOGY GROUP, LLC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3300 S FISKE BLVD | ||||||||
| Address2: | |||||||||
| City: | ROCKLEDGE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329554306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4079602112 | ||||||||
| FaxNumber: | 4079607024 | ||||||||
| Practice Location | |||||||||
| Address1: | 2035 GLENWOOD DR | ||||||||
| Address2: | |||||||||
| City: | WINTER PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327923307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4079602112 | ||||||||
| FaxNumber: | 4079607024 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2019 | ||||||||
| LastUpdateDate: | 03/01/2022 | ||||||||
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| AuthorizedOfficialLastName: | WORLEY | ||||||||
| AuthorizedOfficialFirstName: | AMEIGH | ||||||||
| AuthorizedOfficialMiddleName: | VERDEROSA | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 3217941864 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080A0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine | 207V00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | NP414 | 01 | FL | FL MEDICARE | OTHER | PENDING | 05 | FL | MEDICAID |