Provider Demographics
NPI:1164560124
Name:WEST FLORIDA MEDICAL ASSOCIATES P A
Entity Type:Organization
Organization Name:WEST FLORIDA MEDICAL ASSOCIATES P A
Other - Org Name:HERNANDO MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:SHIRISHKUMAR
Authorized Official - Middle Name:G
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-637-2550
Mailing Address - Street 1:PO BOX 640573
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:FL
Mailing Address - Zip Code:34464-0573
Mailing Address - Country:US
Mailing Address - Phone:352-746-1558
Mailing Address - Fax:352-746-3838
Practice Address - Street 1:2669 N FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:HERNANDO
Practice Address - State:FL
Practice Address - Zip Code:34442
Practice Address - Country:US
Practice Address - Phone:352-637-2550
Practice Address - Fax:352-637-2551
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2010-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0050533261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL660089100Medicaid
FL660089100Medicaid