Provider Demographics
NPI:1023209095
Name:ORMOND INTERNAL MEDICINE LLC
Entity Type:Organization
Organization Name:ORMOND INTERNAL MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICIA GAIL
Authorized Official - Middle Name:
Authorized Official - Last Name:VANDIEPEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:386-673-2133
Mailing Address - Street 1:279 S. YONGE ST.
Mailing Address - Street 2:
Mailing Address - City:ORMOND BCH
Mailing Address - State:FL
Mailing Address - Zip Code:32174
Mailing Address - Country:US
Mailing Address - Phone:386-673-2133
Mailing Address - Fax:386-673-2743
Practice Address - Street 1:279 S. YONGE ST.
Practice Address - Street 2:
Practice Address - City:ORMOND BCH
Practice Address - State:FL
Practice Address - Zip Code:32174
Practice Address - Country:US
Practice Address - Phone:386-673-2133
Practice Address - Fax:386-673-2743
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-06
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS7544207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK4856Medicare UPIN