Provider Demographics
NPI:1134419872
Name:FAMILY PSYCHIATRY, INC.
Entity type:Organization
Organization Name:FAMILY PSYCHIATRY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CORPORATION
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIANNE
Authorized Official - Middle Name:G
Authorized Official - Last Name:KROUK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:239-220-3543
Mailing Address - Street 1:5031 HARBORTOWN LN
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-4650
Mailing Address - Country:US
Mailing Address - Phone:239-220-3543
Mailing Address - Fax:
Practice Address - Street 1:12641 WORLD PLAZA LN
Practice Address - Street 2:SUITE 56
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-3990
Practice Address - Country:US
Practice Address - Phone:239-220-3543
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-14
Last Update Date:2011-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS101992084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
E64080Medicare UPIN