Provider Demographics
NPI:1578928396
Name:AC MEDICAL PROVIDER, INC.
Entity Type:Organization
Organization Name:AC MEDICAL PROVIDER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:B
Authorized Official - Last Name:PARKHURST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-692-8082
Mailing Address - Street 1:3405 NW FEDERAL HWY
Mailing Address - Street 2:
Mailing Address - City:JENSEN BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:34957
Mailing Address - Country:US
Mailing Address - Phone:772-692-8082
Mailing Address - Fax:772-232-9383
Practice Address - Street 1:4340 W NEWBERRY RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32607-2586
Practice Address - Country:US
Practice Address - Phone:772-692-8082
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TREASURE COAST MEDICAL ASSOICATES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-12-21
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME74643207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
K5172Medicare PIN