Provider Demographics
NPI:1235453168
Name:FLORIDA MEDICAL CENTER
Entity Type:Organization
Organization Name:FLORIDA MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MANUEL
Authorized Official - Middle Name:DE JESUS
Authorized Official - Last Name:GAINZA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:772-224-2467
Mailing Address - Street 1:10616 S FEDERAL HWY
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-6401
Mailing Address - Country:US
Mailing Address - Phone:772-224-2467
Mailing Address - Fax:
Practice Address - Street 1:10616 S FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-6401
Practice Address - Country:US
Practice Address - Phone:772-224-2467
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-22
Last Update Date:2010-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME86679207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty