Provider Demographics
NPI:1801865357
Name:FANA MEDICAL GROUP PA
Entity Type:Organization
Organization Name:FANA MEDICAL GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR & OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MIGUEL
Authorized Official - Middle Name:ANTONIO
Authorized Official - Last Name:FANA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-384-0192
Mailing Address - Street 1:5798 38TH AVENUE NORTH
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33710-1926
Mailing Address - Country:US
Mailing Address - Phone:727-384-0192
Mailing Address - Fax:727-384-1500
Practice Address - Street 1:5798 38TH AVENUE NORTH
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-1926
Practice Address - Country:US
Practice Address - Phone:727-384-0192
Practice Address - Fax:727-384-1500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-16
Last Update Date:2013-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME80639207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLH22163Medicare UPIN
FLK8848Medicare PIN