Provider Demographics
NPI:1063477420
Name:JORGE L HERNANDEZ MD PA
Entity Type:Organization
Organization Name:JORGE L HERNANDEZ MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:L
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:941-746-4151
Mailing Address - Street 1:250 2ND ST E
Mailing Address - Street 2:SUITE 3B
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34208-1029
Mailing Address - Country:US
Mailing Address - Phone:941-746-4151
Mailing Address - Fax:941-746-4345
Practice Address - Street 1:250 2ND ST E
Practice Address - Street 2:SUITE 3B
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34208-1029
Practice Address - Country:US
Practice Address - Phone:941-746-4151
Practice Address - Fax:941-746-4345
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-19
Last Update Date:2010-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDB6894OtherMCR RR
FLDB6894OtherMCR RR
FLK5643Medicare PIN