Provider Demographics
NPI:1639585466
Name:FAMILY MEDICAL CLINIC
Entity Type:Organization
Organization Name:FAMILY MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAJAN
Authorized Official - Middle Name:KUMAR
Authorized Official - Last Name:SAREEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-694-2161
Mailing Address - Street 1:PO BOX 51108
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33994-1108
Mailing Address - Country:US
Mailing Address - Phone:239-694-2161
Mailing Address - Fax:239-694-4131
Practice Address - Street 1:4801 PALM BEACH BLVD
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33905-3214
Practice Address - Country:US
Practice Address - Phone:239-694-2161
Practice Address - Fax:239-694-4131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-01
Last Update Date:2014-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL048663900Medicaid
FLD84949Medicare UPIN