Provider Demographics
NPI:1043551468
Name:ID CONSULTS AND SERVICES, PA
Entity Type:Organization
Organization Name:ID CONSULTS AND SERVICES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DARRYL
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-977-5056
Mailing Address - Street 1:3142 NORTHSIDE DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:KEY WEST
Mailing Address - State:FL
Mailing Address - Zip Code:33040-8012
Mailing Address - Country:US
Mailing Address - Phone:305-615-3300
Mailing Address - Fax:
Practice Address - Street 1:3142 NORTHSIDE DR
Practice Address - Street 2:SUITE 101
Practice Address - City:KEY WEST
Practice Address - State:FL
Practice Address - Zip Code:33040-8012
Practice Address - Country:US
Practice Address - Phone:305-615-3300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-11
Last Update Date:2013-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 114239207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty