Provider Demographics
NPI:1528203593
Name:SSP MEDICINE INC
Entity Type:Organization
Organization Name:SSP MEDICINE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEX
Authorized Official - Middle Name:
Authorized Official - Last Name:KHROMOV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-742-4343
Mailing Address - Street 1:1565 SAXON BLVD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:DELTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32725-5876
Mailing Address - Country:US
Mailing Address - Phone:386-742-4343
Mailing Address - Fax:
Practice Address - Street 1:1565 SAXON BLVD
Practice Address - Street 2:SUITE 204
Practice Address - City:DELTONA
Practice Address - State:FL
Practice Address - Zip Code:32725-5876
Practice Address - Country:US
Practice Address - Phone:386-742-4343
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-04
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME96564261QM2500X, 261QR0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)