Provider Demographics
NPI:1356689111
Name:FANA MEDICAL GROUP PORT RICHEY LLC
Entity Type:Organization
Organization Name:FANA MEDICAL GROUP PORT RICHEY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MIGUEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:FANA
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:813-382-7898
Mailing Address - Street 1:5537 GULF DR
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34652-4021
Mailing Address - Country:US
Mailing Address - Phone:727-849-2600
Mailing Address - Fax:727-847-7703
Practice Address - Street 1:7505 ROTTINGHAM RD
Practice Address - Street 2:
Practice Address - City:PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34668-2648
Practice Address - Country:US
Practice Address - Phone:727-849-2600
Practice Address - Fax:727-847-7703
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-29
Last Update Date:2013-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME80639207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty