Provider Demographics
NPI:1326386293
Name:FLORIDA MEDICAL PRACTICE PLAN INC
Entity Type:Organization
Organization Name:FLORIDA MEDICAL PRACTICE PLAN INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:P
Authorized Official - Last Name:FOGARTY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-644-5024
Mailing Address - Street 1:2911 ROBERTS AVE
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32310-5007
Mailing Address - Country:US
Mailing Address - Phone:850-644-1542
Mailing Address - Fax:855-230-7421
Practice Address - Street 1:2911 ROBERTS AVE
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32310-5007
Practice Address - Country:US
Practice Address - Phone:850-644-1543
Practice Address - Fax:855-230-7421
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-28
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC18113359504OtherNPI
FL276305209Medicaid