Provider Demographics
NPI:1598164451
Name:ONSITE MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:ONSITE MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF OPERATIONS AND COMPLIANCE
Authorized Official - Prefix:
Authorized Official - First Name:FERNANDO
Authorized Official - Middle Name:
Authorized Official - Last Name:GANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-801-2664
Mailing Address - Street 1:12269 HICKORY FOREST RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32226-4201
Mailing Address - Country:US
Mailing Address - Phone:407-801-2664
Mailing Address - Fax:877-987-4232
Practice Address - Street 1:3200 W COLONIAL DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32808-8023
Practice Address - Country:US
Practice Address - Phone:407-801-2664
Practice Address - Fax:877-987-4232
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-17
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLL14000123143174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty