Provider Demographics
NPI:1831136274
Name:FLORIDA INTERNAL MEDICINE PA
Entity Type:Organization
Organization Name:FLORIDA INTERNAL MEDICINE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:F
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-333-2503
Mailing Address - Street 1:4106 W LAKE MARY BLVD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-3315
Mailing Address - Country:US
Mailing Address - Phone:407-333-2503
Mailing Address - Fax:407-333-0962
Practice Address - Street 1:4106 W LAKE MARY BLVD
Practice Address - Street 2:SUITE 301
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-3315
Practice Address - Country:US
Practice Address - Phone:407-333-2503
Practice Address - Fax:407-333-0962
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-02
Last Update Date:2007-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL59294ZMedicare UPIN
FL98593Medicare ID - Type UnspecifiedFLORIDA INTERNAL MEDICINE
FL59294ZMedicare ID - Type UnspecifiedGLEN F. DAVIS, M.D.
FLE11977Medicare UPIN
FL59938ZMedicare ID - Type UnspecifiedJOHN F. RYAN, M.D.