Provider Demographics
NPI: | 1942640057 |
---|---|
Name: | NEWSOME MEDICAL LLC |
Entity Type: | Organization |
Organization Name: | NEWSOME MEDICAL LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | MEDICAL DIRECTOR |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | LADAPO |
Authorized Official - Middle Name: | O |
Authorized Official - Last Name: | SHYNGLE |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | MD |
Authorized Official - Phone: | 863-422-0001 |
Mailing Address - Street 1: | 121 WEBB DR |
Mailing Address - Street 2: | SUITE 100 |
Mailing Address - City: | DAVENPORT |
Mailing Address - State: | FL |
Mailing Address - Zip Code: | 33837-3904 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 863-422-0001 |
Mailing Address - Fax: | 863-422-0003 |
Practice Address - Street 1: | 121 WEBB DR |
Practice Address - Street 2: | SUITE 100 |
Practice Address - City: | DAVENPORT |
Practice Address - State: | FL |
Practice Address - Zip Code: | 33837-3904 |
Practice Address - Country: | US |
Practice Address - Phone: | 863-422-0001 |
Practice Address - Fax: | 863-422-0003 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2013-07-03 |
Last Update Date: | 2014-07-21 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
FL | ME 94349 | 261QH0100X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 261QH0100X | Ambulatory Health Care Facilities | Clinic/Center | Health Service |