Provider Demographics
NPI:1114449345
Name:ADVANCE MEDICAL SPECIALTY LLC
Entity Type:Organization
Organization Name:ADVANCE MEDICAL SPECIALTY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HEMWATTIE
Authorized Official - Middle Name:S
Authorized Official - Last Name:JAIMANGAL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:352-633-9858
Mailing Address - Street 1:18981 US HIGHWAY 441 STE 121
Mailing Address - Street 2:
Mailing Address - City:MOUNT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32757-6735
Mailing Address - Country:US
Mailing Address - Phone:352-201-5949
Mailing Address - Fax:352-729-2287
Practice Address - Street 1:8550 NE 138TH LN STE 121
Practice Address - Street 2:
Practice Address - City:LADY LAKE
Practice Address - State:FL
Practice Address - Zip Code:32159-8957
Practice Address - Country:US
Practice Address - Phone:352-633-9858
Practice Address - Fax:352-633-9870
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-10
Last Update Date:2018-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS10278207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL021679600Medicaid