Provider Demographics
NPI:1619139151
Name:FIFTY THIRD AVE EAST MEDICAL CLINIC
Entity Type:Organization
Organization Name:FIFTY THIRD AVE EAST MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PADMINI
Authorized Official - Middle Name:
Authorized Official - Last Name:RAJAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-755-2456
Mailing Address - Street 1:712 53RD AVE E
Mailing Address - Street 2:SUITE C
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34203-5827
Mailing Address - Country:US
Mailing Address - Phone:941-755-2456
Mailing Address - Fax:941-932-4795
Practice Address - Street 1:3900 CLARK RD
Practice Address - Street 2:SUITE B3 & B4
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34233-2301
Practice Address - Country:US
Practice Address - Phone:941-755-2456
Practice Address - Fax:941-932-4795
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FIFTY THIRD AVE EAST MEDICAL CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-06-26
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0049009207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL39646Medicare PIN