Provider Demographics
NPI:1316192867
Name:MARINER PRIMECARE MEDICAL CENTER LLC
Entity Type:Organization
Organization Name:MARINER PRIMECARE MEDICAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:REVELLO
Authorized Official - Suffix:
Authorized Official - Credentials:MPH
Authorized Official - Phone:813-514-6750
Mailing Address - Street 1:7056 MARINER BLVD
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34609-1000
Mailing Address - Country:US
Mailing Address - Phone:352-597-5557
Mailing Address - Fax:352-597-0552
Practice Address - Street 1:7056 MARINER BLVD
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:FL
Practice Address - Zip Code:34609-1000
Practice Address - Country:US
Practice Address - Phone:352-597-5557
Practice Address - Fax:352-597-0552
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-25
Last Update Date:2008-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME83175208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE5540Medicare PIN