Provider Demographics
NPI:1255650636
Name:E & M MEDICAL GROUP PA
Entity Type:Organization
Organization Name:E & M MEDICAL GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:PENA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:863-619-5999
Mailing Address - Street 1:PO BOX 550
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33846-0550
Mailing Address - Country:US
Mailing Address - Phone:863-619-5999
Mailing Address - Fax:863-619-5995
Practice Address - Street 1:4730 EXPLORATION AVE
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33812-3319
Practice Address - Country:US
Practice Address - Phone:863-619-5999
Practice Address - Fax:863-619-5995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-24
Last Update Date:2010-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME90788207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLI10589Medicare UPIN