Provider Demographics
NPI:1023379450
Name:RUSKIN CONVENIENT MEDICAL WALK-IN
Entity Type:Organization
Organization Name:RUSKIN CONVENIENT MEDICAL WALK-IN
Other - Org Name:CONVENIENT MEDICAL
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:JO
Authorized Official - Last Name:CARTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-645-9009
Mailing Address - Street 1:1611 E SHELL POINT RD
Mailing Address - Street 2:
Mailing Address - City:RUSKIN
Mailing Address - State:FL
Mailing Address - Zip Code:33570-5087
Mailing Address - Country:US
Mailing Address - Phone:813-645-9009
Mailing Address - Fax:813-902-6436
Practice Address - Street 1:1611 E SHELL POINT RD
Practice Address - Street 2:
Practice Address - City:RUSKIN
Practice Address - State:FL
Practice Address - Zip Code:33570-5087
Practice Address - Country:US
Practice Address - Phone:813-645-9009
Practice Address - Fax:813-902-6436
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-01
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME31419261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL065544900Medicaid
XC3562205OtherDEA
FL065544900Medicaid
FL065544900Medicaid
BC3562205OtherDEA