Provider Demographics
NPI:1366816514
Name:FAMILY MEDICINE SPECIALISTS, S.C.
Entity Type:Organization
Organization Name:FAMILY MEDICINE SPECIALISTS, S.C.
Other - Org Name:FAMILY MEDICINE SPECIALISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:JASMINE
Authorized Official - Middle Name:
Authorized Official - Last Name:WORTHEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-755-0693
Mailing Address - Street 1:311 PARK PLACE BLVD
Mailing Address - Street 2:5TH FLOOR
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33759-4904
Mailing Address - Country:US
Mailing Address - Phone:727-755-0693
Mailing Address - Fax:
Practice Address - Street 1:431 W LIBERTY STREET
Practice Address - Street 2:
Practice Address - City:WAUCONDA
Practice Address - State:IL
Practice Address - Zip Code:60084
Practice Address - Country:US
Practice Address - Phone:847-508-5897
Practice Address - Fax:847-526-2017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-25
Last Update Date:2015-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036083207Medicaid