Provider Demographics
NPI:1437516689
Name:CLYDE C VANTERPOOL MD PA
Entity Type:Organization
Organization Name:CLYDE C VANTERPOOL MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CLYDE
Authorized Official - Middle Name:CALENSO
Authorized Official - Last Name:VANTERPOOL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:863-991-9060
Mailing Address - Street 1:PO BOX 9034
Mailing Address - Street 2:
Mailing Address - City:SEBRING
Mailing Address - State:FL
Mailing Address - Zip Code:33872-0134
Mailing Address - Country:US
Mailing Address - Phone:863-991-9060
Mailing Address - Fax:863-991-9069
Practice Address - Street 1:6801 US HIGHWAY 27 N STE B1
Practice Address - Street 2:
Practice Address - City:SEBRING
Practice Address - State:FL
Practice Address - Zip Code:33870-1000
Practice Address - Country:US
Practice Address - Phone:863-991-9060
Practice Address - Fax:863-991-9069
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-19
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME67760174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL377470800Medicaid
FL26567Medicare PIN
FLF42068Medicare UPIN