Provider Demographics
NPI:1629814512
Name:FL MOBILE MEDICAL PA
Entity type:Organization
Organization Name:FL MOBILE MEDICAL PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:
Authorized Official - Last Name:GANDELMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:917-477-9028
Mailing Address - Street 1:81 HOLLY HILL LN FL 3
Mailing Address - Street 2:
Mailing Address - City:GREENWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06830-2945
Mailing Address - Country:US
Mailing Address - Phone:203-869-5515
Mailing Address - Fax:
Practice Address - Street 1:4033 TAMPA RD STE 100
Practice Address - Street 2:
Practice Address - City:OLDSMAR
Practice Address - State:FL
Practice Address - Zip Code:34677-3224
Practice Address - Country:US
Practice Address - Phone:203-869-5515
Practice Address - Fax:203-869-5765
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-01
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty