Provider Demographics
NPI:1487638219
Name:INTERVENTIONAL MEDICAL ASSOCIATES LLC
Entity Type:Organization
Organization Name:INTERVENTIONAL MEDICAL ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROBYN
Authorized Official - Middle Name:
Authorized Official - Last Name:GANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-331-3353
Mailing Address - Street 1:6821 NW 11TH PL
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32605-4216
Mailing Address - Country:US
Mailing Address - Phone:352-331-3353
Mailing Address - Fax:352-333-9035
Practice Address - Street 1:6821 NW 11TH PL
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32605-4216
Practice Address - Country:US
Practice Address - Phone:352-331-3353
Practice Address - Fax:352-333-9035
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-05
Last Update Date:2014-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME82864174400000X
FLME76862174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6960350001Medicare NSC
D75042Medicare UPIN
K9118Medicare PIN