Provider Demographics
NPI:1861437451
Name:ADVANCED GYNECOLOGY OF CENTRAL FLORIDA P A
Entity type:Organization
Organization Name:ADVANCED GYNECOLOGY OF CENTRAL FLORIDA P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LANE
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:MERCER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-898-9804
Mailing Address - Street 1:2501 N ORANGE AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-4603
Mailing Address - Country:US
Mailing Address - Phone:407-898-9804
Mailing Address - Fax:407-898-9805
Practice Address - Street 1:2501 N ORANGE AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-4603
Practice Address - Country:US
Practice Address - Phone:407-898-9804
Practice Address - Fax:407-898-9805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-18
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME89606207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL49013AMedicare ID - Type Unspecified
FLC39281Medicare UPIN