Provider Demographics
NPI:1598114779
Name:MIDWAY PRIMARY CARE LLC
Entity Type:Organization
Organization Name:MIDWAY PRIMARY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOARD MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:
Authorized Official - Last Name:HAYDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-464-9746
Mailing Address - Street 1:356 E MIDWAY RD
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34982-7148
Mailing Address - Country:US
Mailing Address - Phone:772-464-9746
Mailing Address - Fax:
Practice Address - Street 1:3255 S US HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34982-6381
Practice Address - Country:US
Practice Address - Phone:772-742-9470
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MIDWAY SPECIALTY CARE CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-06-08
Last Update Date:2022-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty