Provider Demographics
NPI:1871641209
Name:FERNHILL FAMILY MEDICINE LLC
Entity Type:Organization
Organization Name:FERNHILL FAMILY MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECT OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KUMARAN
Authorized Official - Middle Name:KONDATH
Authorized Official - Last Name:MOHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-589-9090
Mailing Address - Street 1:4601 N HIGHWAY 19A
Mailing Address - Street 2:
Mailing Address - City:MOUNT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32757-2039
Mailing Address - Country:US
Mailing Address - Phone:352-589-9090
Mailing Address - Fax:352-589-1433
Practice Address - Street 1:4601 N HIGHWAY 19A
Practice Address - Street 2:
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-2039
Practice Address - Country:US
Practice Address - Phone:352-589-9090
Practice Address - Fax:352-589-1433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 83819207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL265990500Medicaid
FL62884Medicare ID - Type Unspecified
FL265990500Medicaid