Provider Demographics
NPI:1467870311
Name:PHYSICIANS TRUST MSO, LLC
Entity Type:Organization
Organization Name:PHYSICIANS TRUST MSO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:E
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-475-9213
Mailing Address - Street 1:1101 N LAKE DESTINY DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-7114
Mailing Address - Country:US
Mailing Address - Phone:407-475-9213
Mailing Address - Fax:407-475-9203
Practice Address - Street 1:1101 N LAKE DESTINY DR
Practice Address - Street 2:SUITE 300
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-7114
Practice Address - Country:US
Practice Address - Phone:407-475-9213
Practice Address - Fax:407-475-9203
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-28
Last Update Date:2014-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty