Provider Demographics
NPI:1326196924
Name:FIDELITY MEDICAL SERVICES PLC DBA MID-TOWN CENTER FOR HEALTH
Entity Type:Organization
Organization Name:FIDELITY MEDICAL SERVICES PLC DBA MID-TOWN CENTER FOR HEALTH
Other - Org Name:MID-TOWN CENTER FOR HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-421-2119
Mailing Address - Street 1:701 OHIO AVE S
Mailing Address - Street 2:
Mailing Address - City:LIVE OAK
Mailing Address - State:FL
Mailing Address - Zip Code:32064-3816
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:701 OHIO AVE S
Practice Address - Street 2:
Practice Address - City:LIVE OAK
Practice Address - State:FL
Practice Address - Zip Code:32064-3816
Practice Address - Country:US
Practice Address - Phone:386-330-5248
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL=========OtherFEIN NUMBER