Provider Demographics
NPI:1174834717
Name:AMA MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:AMA MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CRUZ
Authorized Official - Middle Name:MARTINA
Authorized Official - Last Name:FANA-SOUCHET
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-331-8740
Mailing Address - Street 1:PO BOX 306
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34682-0306
Mailing Address - Country:US
Mailing Address - Phone:727-331-8740
Mailing Address - Fax:727-331-8744
Practice Address - Street 1:125 PATRICIA AVE
Practice Address - Street 2:UNITS B & D
Practice Address - City:DUNEDIN
Practice Address - State:FL
Practice Address - Zip Code:34698-8100
Practice Address - Country:US
Practice Address - Phone:727-331-8740
Practice Address - Fax:727-331-8744
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-29
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 96750207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty