Provider Demographics
NPI:1821339755
Name:B RAI GUPTA MD PA
Entity Type:Organization
Organization Name:B RAI GUPTA MD PA
Other - Org Name:FL CENTER FOR PLASTIC & HAND SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS ACCOUNT MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:HOLLAND
Authorized Official - Suffix:
Authorized Official - Credentials:BSN
Authorized Official - Phone:407-321-7111
Mailing Address - Street 1:3300 W LAKE MARY BLVD
Mailing Address - Street 2:SUITE 220
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-3570
Mailing Address - Country:US
Mailing Address - Phone:407-321-7111
Mailing Address - Fax:407-321-7446
Practice Address - Street 1:3300 W LAKE MARY BLVD
Practice Address - Street 2:SUITE 220
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-3570
Practice Address - Country:US
Practice Address - Phone:407-321-7111
Practice Address - Fax:407-321-7446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-01
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLF62874Medicare UPIN