Provider Demographics
NPI:1790839678
Name:NORTH FLORIDA MEDICAL CORP.
Entity Type:Organization
Organization Name:NORTH FLORIDA MEDICAL CORP.
Other - Org Name:UNION MEDICAL SUPPLY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SALVADOR
Authorized Official - Middle Name:ANTONIO
Authorized Official - Last Name:PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-496-1575
Mailing Address - Street 1:655 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LAKE BUTLER
Mailing Address - State:FL
Mailing Address - Zip Code:32054-1352
Mailing Address - Country:US
Mailing Address - Phone:386-496-3656
Mailing Address - Fax:
Practice Address - Street 1:655 E MAIN ST
Practice Address - Street 2:
Practice Address - City:LAKE BUTLER
Practice Address - State:FL
Practice Address - Zip Code:32054-1352
Practice Address - Country:US
Practice Address - Phone:386-496-3656
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2012-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL576332B00000X
FL32011614332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLM1087OtherBLUE CROSS BLUE SHIELD
FL027755000Medicaid
FL0724220001Medicare ID - Type Unspecified