Provider Demographics
NPI:1235218405
Name:INFECTIOUS DISEASE GROUP, PA
Entity Type:Organization
Organization Name:INFECTIOUS DISEASE GROUP, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF CORPORATION
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:SIDNEY
Authorized Official - Last Name:CLEMENTS
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:850-432-3692
Mailing Address - Street 1:1717 N E ST
Mailing Address - Street 2:SUITE 439
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32501-6339
Mailing Address - Country:US
Mailing Address - Phone:850-432-3692
Mailing Address - Fax:800-918-3765
Practice Address - Street 1:1717 N E ST
Practice Address - Street 2:SUITE 439
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32501-6339
Practice Address - Country:US
Practice Address - Phone:850-432-3692
Practice Address - Fax:800-918-3765
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL377030300Medicaid
AL529502140Medicaid
AL529502140Medicaid