Provider Demographics
NPI:1568893428
Name:MDLIVE MEDICAL GROUP WI SC
Entity Type:Organization
Organization Name:MDLIVE MEDICAL GROUP WI SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:MOTARJEME
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:855-332-4499
Mailing Address - Street 1:4350 FOWLER ST STE 21
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-2616
Mailing Address - Country:US
Mailing Address - Phone:855-332-4499
Mailing Address - Fax:231-932-4133
Practice Address - Street 1:13630 NW 8TH ST STE 205
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33325-6238
Practice Address - Country:US
Practice Address - Phone:855-332-4499
Practice Address - Fax:231-932-4133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-03
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty