Provider Demographics
NPI:1083016414
Name:EXPRESS CARE CLINIC GROUP
Entity Type:Organization
Organization Name:EXPRESS CARE CLINIC GROUP
Other - Org Name:EXPRESS CARE CLINIC GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:OLEKSANDR
Authorized Official - Middle Name:V
Authorized Official - Last Name:ONUSHKO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-475-3366
Mailing Address - Street 1:2650 W STATE ROAD 434
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32779-4815
Mailing Address - Country:US
Mailing Address - Phone:407-475-3366
Mailing Address - Fax:407-475-3367
Practice Address - Street 1:2650 W STATE ROAD 434
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32779-4815
Practice Address - Country:US
Practice Address - Phone:407-475-3366
Practice Address - Fax:407-475-3367
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-17
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty