Provider Demographics
NPI:1649218694
Name:KINGS BAY FAMILY CARE PA
Entity Type:Organization
Organization Name:KINGS BAY FAMILY CARE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:B
Authorized Official - Last Name:MUELLER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:352-795-2273
Mailing Address - Street 1:14690 SPRING HILL DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34609-8102
Mailing Address - Country:US
Mailing Address - Phone:352-795-2273
Mailing Address - Fax:352-795-2296
Practice Address - Street 1:9030 W FORT ISLAND TRL
Practice Address - Street 2:SUITE 1
Practice Address - City:CRYSTAL RIVER
Practice Address - State:FL
Practice Address - Zip Code:34429-2412
Practice Address - Country:US
Practice Address - Phone:352-795-2273
Practice Address - Fax:352-795-2296
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS7801207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDS4782OtherRAILROAD MEDICARE
FL46431OtherBCBS
FLK3294Medicare ID - Type Unspecified
FLDS4782OtherRAILROAD MEDICARE