Provider Demographics
NPI:1093493637
Name:ADVENTHEALTH PRIMARY CARE NETWORK INC
Entity Type:Organization
Organization Name:ADVENTHEALTH PRIMARY CARE NETWORK INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SVP-CFO
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:J
Authorized Official - Last Name:PETTIJOHN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-357-1000
Mailing Address - Street 1:900 HOPE WAY
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32714-1502
Mailing Address - Country:US
Mailing Address - Phone:407-357-1000
Mailing Address - Fax:
Practice Address - Street 1:900 HOPE WAY
Practice Address - Street 2:
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32714-1502
Practice Address - Country:US
Practice Address - Phone:407-357-1000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-05
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty