Provider Demographics
NPI:1679883151
Name:PHYSICIAN MANAGEMENT SERVICES OF FLORIDA LLC
Entity type:Organization
Organization Name:PHYSICIAN MANAGEMENT SERVICES OF FLORIDA LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CASEY
Authorized Official - Middle Name:
Authorized Official - Last Name:DELOACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:888-829-8550
Mailing Address - Street 1:400 GATLIN AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-6940
Mailing Address - Country:US
Mailing Address - Phone:888-829-8550
Mailing Address - Fax:888-843-7191
Practice Address - Street 1:400 GATLIN AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-6940
Practice Address - Country:US
Practice Address - Phone:888-829-8550
Practice Address - Fax:888-843-7191
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VAXCARE CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-10-18
Last Update Date:2013-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PHC059OtherMEDICARE PTAN