Provider Demographics
NPI:1457506495
Name:MID FLORIDA MEDICAL
Entity Type:Organization
Organization Name:MID FLORIDA MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:KNIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-422-2612
Mailing Address - Street 1:32641 RADIO RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34788-3978
Mailing Address - Country:US
Mailing Address - Phone:352-728-1524
Mailing Address - Fax:352-728-5142
Practice Address - Street 1:32641 RADIO RD
Practice Address - Street 2:SUITE 101
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34788-3978
Practice Address - Country:US
Practice Address - Phone:352-728-1524
Practice Address - Fax:352-728-5142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-18
Last Update Date:2008-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022645900Medicaid
FL022645900Medicaid