Provider Demographics
NPI:1275683682
Name:NATURE COAST MEDICAL GROUP PA
Entity Type:Organization
Organization Name:NATURE COAST MEDICAL GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:L
Authorized Official - Last Name:MCCOY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:352-528-5801
Mailing Address - Street 1:130 SW 7TH ST
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:FL
Mailing Address - Zip Code:32696-2404
Mailing Address - Country:US
Mailing Address - Phone:352-528-5801
Mailing Address - Fax:352-528-6019
Practice Address - Street 1:130 SW 7TH ST
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:FL
Practice Address - Zip Code:32696-2404
Practice Address - Country:US
Practice Address - Phone:352-528-5801
Practice Address - Fax:352-528-6019
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0011887207Q00000X
FLOS0005395207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL043550300Medicaid
FL68-3803OtherMEDICARE RURAL HEALTH CLINIC
FL049437203Medicaid
FLD85690Medicare UPIN
FLE72671Medicare UPIN
FL049437203Medicaid
FL68-3803OtherMEDICARE RURAL HEALTH CLINIC