Provider Demographics
NPI:1851433197
Name:HAILE MEDICAL GROUP PA
Entity Type:Organization
Organization Name:HAILE MEDICAL GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:NICHOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:OSBORNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-367-9602
Mailing Address - Street 1:4750 SW 91ST DR STE A
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32608-8140
Mailing Address - Country:US
Mailing Address - Phone:352-367-9602
Mailing Address - Fax:
Practice Address - Street 1:4750 SW 91ST DR STE A
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32608-8140
Practice Address - Country:US
Practice Address - Phone:352-367-9602
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2009-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK0934Medicare PIN