Provider Demographics
NPI:1760715973
Name:FLORIDA HOSPITAL MEDICAL GROUP INC
Entity Type:Organization
Organization Name:FLORIDA HOSPITAL MEDICAL GROUP INC
Other - Org Name:BREAST CARE CENTER OF FLORIDA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:VANCE
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:MCLARREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-200-2700
Mailing Address - Street 1:1925 MIZELL AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32792-4155
Mailing Address - Country:US
Mailing Address - Phone:076-467-4104
Mailing Address - Fax:407-646-7412
Practice Address - Street 1:1925 MIZELL AVE STE 105
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-4155
Practice Address - Country:US
Practice Address - Phone:076-467-4104
Practice Address - Fax:407-646-7412
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FLORIDA HOSPITAL MEDICAL GROUP INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-09-08
Last Update Date:2023-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL237620261QR0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0206XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mammography
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL237620OtherMAMMOGRAPHY CERT#