Provider Demographics
NPI:1093852931
Name:WEST FLORIDA MEDICAL ASSOCIATES P A
Entity Type:Organization
Organization Name:WEST FLORIDA MEDICAL ASSOCIATES P A
Other - Org Name:BELLAM MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RAJENDRA
Authorized Official - Middle Name:P
Authorized Official - Last Name:BELLAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-447-3031
Mailing Address - Street 1:PO BOX 69
Mailing Address - Street 2:41 N. INGLIS AVE
Mailing Address - City:INGLIS
Mailing Address - State:FL
Mailing Address - Zip Code:34449-0069
Mailing Address - Country:US
Mailing Address - Phone:352-447-3031
Mailing Address - Fax:
Practice Address - Street 1:41 N INGLIS AVE
Practice Address - Street 2:
Practice Address - City:INGLIS
Practice Address - State:FL
Practice Address - Zip Code:34449-9463
Practice Address - Country:US
Practice Address - Phone:352-447-3031
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2010-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0060472261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL660142100Medicaid
FL660142100Medicaid