Provider Demographics
NPI:1003002759
Name:MOBILE PHYSICIAN SERVICES INC.
Entity Type:Organization
Organization Name:MOBILE PHYSICIAN SERVICES INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:M
Authorized Official - Last Name:WACKSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:855-232-0644
Mailing Address - Street 1:6804 CECELIA DR
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34653-4935
Mailing Address - Country:US
Mailing Address - Phone:855-232-0644
Mailing Address - Fax:888-546-0488
Practice Address - Street 1:6804 CECELIA DR
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34653-4935
Practice Address - Country:US
Practice Address - Phone:727-232-0644
Practice Address - Fax:888-546-0488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-17
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
152W00000X, 207RH0002X, 2084P0805X, 213ES0103X, 363LA2200X
FLME0086161207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative MedicineGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric PsychiatryGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK9757OtherPTAN
FLK9757AOtherFL PTAN
FLMEDICARE NPIOther1003002759
FL007870000Medicaid
OH0404354Medicaid
FL000MQOtherBCBS GROUP