Provider Demographics
NPI:1629060033
Name:FLORIDA HOSPITAL MEDICAL GROUP INC
Entity Type:Organization
Organization Name:FLORIDA HOSPITAL MEDICAL GROUP INC
Other - Org Name:ORLANDO NEUROSURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:STILTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-200-2733
Mailing Address - Street 1:1605 W FAIRBANKS AVE
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-4603
Mailing Address - Country:US
Mailing Address - Phone:407-975-0200
Mailing Address - Fax:470-975-0209
Practice Address - Street 1:1605 W FAIRBANKS AVE
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-4603
Practice Address - Country:US
Practice Address - Phone:407-975-0200
Practice Address - Fax:470-975-0209
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-22
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL34958OtherBLUE CROSS/BLUE SHIELD
FL268791700Medicaid
FLGN288AMedicare PIN
FL268791700Medicaid
FL34958Medicare ID - Type Unspecified