Provider Demographics
NPI:1982004933
Name:OLD TOWN MEDICAL CENTERS, LLC
Entity Type:Organization
Organization Name:OLD TOWN MEDICAL CENTERS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AP
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:MACKEY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:305-394-1792
Mailing Address - Street 1:540 TRUMAN AVE
Mailing Address - Street 2:
Mailing Address - City:KEY WEST
Mailing Address - State:FL
Mailing Address - Zip Code:33040-3141
Mailing Address - Country:US
Mailing Address - Phone:305-394-1792
Mailing Address - Fax:
Practice Address - Street 1:540 TRUMAN AVE
Practice Address - Street 2:
Practice Address - City:KEY WEST
Practice Address - State:FL
Practice Address - Zip Code:33040-3141
Practice Address - Country:US
Practice Address - Phone:305-394-1792
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-27
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 51339207Q00000X
FLOS9185207R00000X
FL9168222363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty