Provider Demographics
NPI:1043560832
Name:PROMISE MEDICAL GROUP, PLLC
Entity Type:Organization
Organization Name:PROMISE MEDICAL GROUP, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:STEPHENSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-812-0579
Mailing Address - Street 1:2351 CLEARWATER RUN
Mailing Address - Street 2:
Mailing Address - City:THE VILLAGES
Mailing Address - State:FL
Mailing Address - Zip Code:32162
Mailing Address - Country:US
Mailing Address - Phone:352-812-0579
Mailing Address - Fax:
Practice Address - Street 1:2351 CLEARWATER RUN
Practice Address - Street 2:
Practice Address - City:THE VILLAGES
Practice Address - State:FL
Practice Address - Zip Code:32162
Practice Address - Country:US
Practice Address - Phone:352-812-0579
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-19
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME106525207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLFD876ZOtherMEDICARE