Provider Demographics
NPI:1528440781
Name:PRESTIGE MEDICAL GROUP LLC
Entity type:Organization
Organization Name:PRESTIGE MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:JAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-362-4000
Mailing Address - Street 1:6924 PROFESSIONAL PKWY E
Mailing Address - Street 2:STE B
Mailing Address - City:LAKEWOOD RANCH
Mailing Address - State:FL
Mailing Address - Zip Code:34240-8439
Mailing Address - Country:US
Mailing Address - Phone:941-362-4000
Mailing Address - Fax:941-362-4400
Practice Address - Street 1:6924 PROFESSIONAL PKWY E
Practice Address - Street 2:SUITE B
Practice Address - City:LAKEWOOD RANCH
Practice Address - State:FL
Practice Address - Zip Code:34240-8414
Practice Address - Country:US
Practice Address - Phone:941-752-6002
Practice Address - Fax:941-752-6008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-24
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty