Provider Demographics
NPI:1568974798
Name:FYZAMEDICAL LLC
Entity Type:Organization
Organization Name:FYZAMEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:
Authorized Official - First Name:TYLER
Authorized Official - Middle Name:
Authorized Official - Last Name:PENROD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-907-4175
Mailing Address - Street 1:142 BLACKSTONE CREEK RD
Mailing Address - Street 2:
Mailing Address - City:GROVELAND
Mailing Address - State:FL
Mailing Address - Zip Code:34736-3621
Mailing Address - Country:US
Mailing Address - Phone:407-668-5525
Mailing Address - Fax:
Practice Address - Street 1:7209 CURRY FORD RD STE B
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32822-5809
Practice Address - Country:US
Practice Address - Phone:407-501-8563
Practice Address - Fax:512-532-0923
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-27
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes291U00000XLaboratoriesClinical Medical Laboratory
No246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL10D2150190OtherCLIA