Provider Demographics
NPI:1891905378
Name:URGENT CARE CENTER OF PORT ORANGE, LLC
Entity Type:Organization
Organization Name:URGENT CARE CENTER OF PORT ORANGE, LLC
Other - Org Name:PORT ORANGE URGENT CARE, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:AMMAR
Authorized Official - Middle Name:
Authorized Official - Last Name:HEMAIDAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-271-2273
Mailing Address - Street 1:1690 DUNLAWTON AVE
Mailing Address - Street 2:SUITE 120
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-8980
Mailing Address - Country:US
Mailing Address - Phone:386-271-2273
Mailing Address - Fax:386-271-2274
Practice Address - Street 1:1690 DUNLAWTON AVE
Practice Address - Street 2:SUITE 120
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-8980
Practice Address - Country:US
Practice Address - Phone:386-271-2273
Practice Address - Fax:386-271-2274
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2013-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME73758261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL41597ZMedicare UPIN