Provider Demographics
NPI:1275702037
Name:MIDFLORIDA INTERNAL MEDICINE ASSOCIATES, PA
Entity Type:Organization
Organization Name:MIDFLORIDA INTERNAL MEDICINE ASSOCIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTRACTING/CREDENTIALING
Authorized Official - Prefix:MISS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:N
Authorized Official - Last Name:NALKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-293-9500
Mailing Address - Street 1:320 1ST ST N
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33881-4113
Mailing Address - Country:US
Mailing Address - Phone:863-293-9500
Mailing Address - Fax:863-293-4994
Practice Address - Street 1:675 AVENUE L SE
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33880-4219
Practice Address - Country:US
Practice Address - Phone:863-293-9500
Practice Address - Fax:863-293-9511
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-26
Last Update Date:2015-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0068923207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2502488800Medicaid
FLK2500Medicare PIN