Provider Demographics
NPI:1275502098
Name:SUNSHINE STATE MEDICAL
Entity Type:Organization
Organization Name:SUNSHINE STATE MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:ORTIZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-482-0052
Mailing Address - Street 1:5575 S SEMORAN BLVD
Mailing Address - Street 2:#503
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32822
Mailing Address - Country:US
Mailing Address - Phone:407-482-0052
Mailing Address - Fax:407-482-0198
Practice Address - Street 1:5575 S SEMORAN BLVD
Practice Address - Street 2:#503
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32822
Practice Address - Country:US
Practice Address - Phone:407-482-0052
Practice Address - Fax:407-482-0198
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-15
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH9030111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK9436Medicare PIN
FLU96679Medicare UPIN
88974Medicare ID - Type Unspecified