Provider Demographics
NPI:1548600869
Name:PORT ORANGE GYNECOLOGY LLC
Entity Type:Organization
Organization Name:PORT ORANGE GYNECOLOGY LLC
Other - Org Name:PORT ORANGE GYNECOLOGY LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:M.D. OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:M
Authorized Official - Last Name:FOUST
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-492-6929
Mailing Address - Street 1:PO BOX 12051
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4011
Mailing Address - Country:US
Mailing Address - Phone:386-492-6929
Mailing Address - Fax:386-492-6930
Practice Address - Street 1:900 N SWALLOWTAIL DR
Practice Address - Street 2:ST 102B
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32129-6102
Practice Address - Country:US
Practice Address - Phone:386-492-6929
Practice Address - Fax:386-492-6930
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-01
Last Update Date:2013-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME97528207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL277730400Medicaid
FL277730400Medicaid