Provider Demographics
NPI:1285662221
Name:FLORIDA PHYSICIANS MEDICAL GROUP INC
Entity Type:Organization
Organization Name:FLORIDA PHYSICIANS MEDICAL GROUP INC
Other - Org Name:FAMILY PRACTICE CENTER OF AVON PARK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:STILTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-200-2700
Mailing Address - Street 1:PO BOX 538600
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32853-8600
Mailing Address - Country:US
Mailing Address - Phone:407-200-2700
Mailing Address - Fax:407-200-4904
Practice Address - Street 1:1006 W PLEASANT ST
Practice Address - Street 2:
Practice Address - City:AVON PARK
Practice Address - State:FL
Practice Address - Zip Code:33825-2966
Practice Address - Country:US
Practice Address - Phone:863-453-3121
Practice Address - Fax:863-452-2823
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-29
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CG7931Medicare PIN
FLK0589Medicare PIN
103832Medicare Oscar/Certification