Provider Demographics
NPI:1730378241
Name:FAMILY MEDICINE & CLINICAL RESEARCH OF CENTRAL FLORIDA LLC
Entity type:Organization
Organization Name:FAMILY MEDICINE & CLINICAL RESEARCH OF CENTRAL FLORIDA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:GAY
Authorized Official - Suffix:II
Authorized Official - Credentials:PA-C
Authorized Official - Phone:407-451-1849
Mailing Address - Street 1:1603 S HIAWASSEE RD
Mailing Address - Street 2:SUITE 115
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32835-6438
Mailing Address - Country:US
Mailing Address - Phone:407-299-6700
Mailing Address - Fax:407-299-2265
Practice Address - Street 1:1603 S HIAWASSEE RD
Practice Address - Street 2:SUITE 115
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32835-6438
Practice Address - Country:US
Practice Address - Phone:407-299-6700
Practice Address - Fax:407-299-2265
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-21
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102434261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL173000000XOtherPRIMARY TAXONOMY
FLD57952Medicare UPIN
FLU8179ZMedicare Oscar/Certification
FLQ72020Medicare UPIN