Provider Demographics
NPI:1427017466
Name:PHYSICIAN BUSINESS ALLIANCE INC
Entity Type:Organization
Organization Name:PHYSICIAN BUSINESS ALLIANCE INC
Other - Org Name:SPORTS MEDICINE INSTITUTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:DONALD
Authorized Official - Last Name:NOWICKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-242-0404
Mailing Address - Street 1:2020 OAKLEY SEAVER DR
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-1902
Mailing Address - Country:US
Mailing Address - Phone:352-242-0404
Mailing Address - Fax:352-242-0877
Practice Address - Street 1:2020 OAKLEY SEAVER DR
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711
Practice Address - Country:US
Practice Address - Phone:352-242-0404
Practice Address - Fax:352-242-0877
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-20
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL33191OtherBC/BS FL
FL33191OtherBC/BS FL