Provider Demographics
NPI:1134567613
Name:NORTHERN MEDICAL CENTER INC
Entity type:Organization
Organization Name:NORTHERN MEDICAL CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANIIL
Authorized Official - Middle Name:
Authorized Official - Last Name:SUPISHCHEV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-257-4763
Mailing Address - Street 1:12450 TAMIAMI TRL S
Mailing Address - Street 2:SUITE E
Mailing Address - City:NORTH PORT
Mailing Address - State:FL
Mailing Address - Zip Code:34287-1473
Mailing Address - Country:US
Mailing Address - Phone:941-257-4763
Mailing Address - Fax:941-257-4766
Practice Address - Street 1:12450 TAMIAMI TRL S
Practice Address - Street 2:SUITE E
Practice Address - City:NORTH PORT
Practice Address - State:FL
Practice Address - Zip Code:34287-1473
Practice Address - Country:US
Practice Address - Phone:941-257-4763
Practice Address - Fax:941-257-4766
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-06
Last Update Date:2013-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty