Provider Demographics
NPI:1093448102
Name:INCHARGECLINIC
Entity Type:Organization
Organization Name:INCHARGECLINIC
Other - Org Name:JILL MARIE MARSHALL-ALLEN
Other - Org Type:Other Name
Authorized Official - Title/Position:MMGR
Authorized Official - Prefix:
Authorized Official - First Name:JILL
Authorized Official - Middle Name:
Authorized Official - Last Name:MARSHALL-ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:A-APRN
Authorized Official - Phone:813-530-9666
Mailing Address - Street 1:2424 W BRANDON BLVD # 1045
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-4717
Mailing Address - Country:US
Mailing Address - Phone:813-530-9666
Mailing Address - Fax:813-729-8645
Practice Address - Street 1:12250 BLUE PACIFIC DRIVE
Practice Address - Street 2:ADMINISTRATION
Practice Address - City:RIVER VIEW
Practice Address - State:FL
Practice Address - Zip Code:33579
Practice Address - Country:US
Practice Address - Phone:813-530-9666
Practice Address - Fax:813-729-8645
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-06
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Multi-Specialty
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1205877560Medicaid