Provider Demographics
NPI:1164739421
Name:BURNT STORE FAMILY MEDICINE P L
Entity Type:Organization
Organization Name:BURNT STORE FAMILY MEDICINE P L
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:
Authorized Official - Last Name:WANG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:941-505-0974
Mailing Address - Street 1:100 MADRID BLVD
Mailing Address - Street 2:SUITE 513
Mailing Address - City:PUNTA GORDA
Mailing Address - State:FL
Mailing Address - Zip Code:33950-7968
Mailing Address - Country:US
Mailing Address - Phone:941-505-0974
Mailing Address - Fax:941-505-8517
Practice Address - Street 1:100 MADRID BLVD
Practice Address - Street 2:SUITE 513
Practice Address - City:PUNTA GORDA
Practice Address - State:FL
Practice Address - Zip Code:33950-7968
Practice Address - Country:US
Practice Address - Phone:941-505-0974
Practice Address - Fax:941-505-8517
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-08
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0072508207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLEZ857AMedicare PIN