Provider Demographics
NPI:1942795869
Name:ST PETER MEDICAL GROUP INC.
Entity Type:Organization
Organization Name:ST PETER MEDICAL GROUP INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MIRIAM
Authorized Official - Middle Name:L
Authorized Official - Last Name:RIVERA-IRIZARRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-729-8173
Mailing Address - Street 1:PO BOX 582170
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34758-0027
Mailing Address - Country:US
Mailing Address - Phone:407-922-0240
Mailing Address - Fax:
Practice Address - Street 1:339 CYPRESS PKWY STE 110
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34759
Practice Address - Country:US
Practice Address - Phone:407-922-0240
Practice Address - Fax:407-343-5199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-23
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1356304828Medicaid