Provider Demographics
NPI:1790189447
Name:PHYSICIAN ASSOCIATES LLC
Entity Type:Organization
Organization Name:PHYSICIAN ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTRACTING/CREDENTIALING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:SAVAGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-649-7412
Mailing Address - Street 1:235 N WESTMONTE DR
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32714-3345
Mailing Address - Country:US
Mailing Address - Phone:407-262-5710
Mailing Address - Fax:407-389-5312
Practice Address - Street 1:7350 SAND LAKE COMMONS BLVD
Practice Address - Street 2:SUITE 1102
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-8040
Practice Address - Country:US
Practice Address - Phone:407-355-7478
Practice Address - Fax:407-354-2431
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-09
Last Update Date:2017-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME87792207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010694500Medicaid
U1181YMedicare PIN