Provider Demographics
NPI:1508929050
Name:MEDICAL CENTER LLC
Entity Type:Organization
Organization Name:MEDICAL CENTER LLC
Other - Org Name:THE MEDICAL CENTER OF BLOUNTSTOWN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:IQBAL
Authorized Official - Middle Name:A
Authorized Official - Last Name:FAUQUI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-674-2221
Mailing Address - Street 1:20454 NE FINLEY AVE
Mailing Address - Street 2:
Mailing Address - City:BLOUNTSTOWN
Mailing Address - State:FL
Mailing Address - Zip Code:32424-6012
Mailing Address - Country:US
Mailing Address - Phone:850-674-2221
Mailing Address - Fax:850-674-2121
Practice Address - Street 1:20454 NE FINLEY AVE
Practice Address - Street 2:
Practice Address - City:BLOUNTSTOWN
Practice Address - State:FL
Practice Address - Zip Code:32424-6012
Practice Address - Country:US
Practice Address - Phone:850-674-2221
Practice Address - Fax:850-674-2121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL660205300Medicaid
FL660205300Medicaid
108963Medicare Oscar/Certification
108963Medicare PIN