Provider Demographics
NPI:1851861348
Name:MEDICAL INJURY CARE PROVIDER NETWORK
Entity Type:Organization
Organization Name:MEDICAL INJURY CARE PROVIDER NETWORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:OWEN
Authorized Official - Middle Name:D
Authorized Official - Last Name:FRASER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-351-1095
Mailing Address - Street 1:1805 W COLONIAL DR STE A
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-7011
Mailing Address - Country:US
Mailing Address - Phone:407-578-9142
Mailing Address - Fax:
Practice Address - Street 1:1805 W COLONIAL DR STE A
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-7011
Practice Address - Country:US
Practice Address - Phone:407-578-9142
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-28
Last Update Date:2018-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL=========OtherINJURY CARE