Provider Demographics
NPI:1558345173
Name:KISSIMMEE MEDICAL CENTER PA
Entity Type:Organization
Organization Name:KISSIMMEE MEDICAL CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHANTI
Authorized Official - Middle Name:
Authorized Official - Last Name:SINGH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-343-4338
Mailing Address - Street 1:1910 W OAK ST
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-4301
Mailing Address - Country:US
Mailing Address - Phone:407-343-4338
Mailing Address - Fax:407-343-4335
Practice Address - Street 1:1910 W OAK ST
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-4301
Practice Address - Country:US
Practice Address - Phone:407-343-4338
Practice Address - Fax:407-343-4335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-06
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL256014300Medicaid
FL32190AMedicare ID - Type Unspecified
FL256014300Medicaid