Provider Demographics
NPI:1710935994
Name:SEBASTIAN HMA PHYSICIAN MANAGEMENT LLC
Entity Type:Organization
Organization Name:SEBASTIAN HMA PHYSICIAN MANAGEMENT LLC
Other - Org Name:NORTH COUNTY MEDICAL LABORATORY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:DEPUTRON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:772-581-6900
Mailing Address - Street 1:13850 US HIGHWAY 1
Mailing Address - Street 2:
Mailing Address - City:SEBASTIAN
Mailing Address - State:FL
Mailing Address - Zip Code:32958-3231
Mailing Address - Country:US
Mailing Address - Phone:772-581-3366
Mailing Address - Fax:
Practice Address - Street 1:13850 US HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:SEBASTIAN
Practice Address - State:FL
Practice Address - Zip Code:32958-3231
Practice Address - Country:US
Practice Address - Phone:772-581-3366
Practice Address - Fax:772-581-3390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-04
Last Update Date:2010-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL800017216291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLL9231OtherBLUE CROSS BLUE SHIELD
FL690009384OtherRR MEDICARE
FL593733467001OtherTRICARE
FLE7347Medicare ID - Type Unspecified