Provider Demographics
NPI:1144417791
Name:FDM,PLC
Entity Type:Organization
Organization Name:FDM,PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:RAJIVA
Authorized Official - Middle Name:
Authorized Official - Last Name:GOYAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-819-2338
Mailing Address - Street 1:PO BOX 2089
Mailing Address - Street 2:
Mailing Address - City:TARPON SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34688-2089
Mailing Address - Country:US
Mailing Address - Phone:727-819-2338
Mailing Address - Fax:727-819-2481
Practice Address - Street 1:14100 FIVAY RD STE 120
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:FL
Practice Address - Zip Code:34667-7159
Practice Address - Country:US
Practice Address - Phone:727-819-2338
Practice Address - Fax:727-819-2481
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-27
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME80055174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK3303Medicare PIN