Provider Demographics
NPI:1134336209
Name:ANGLIN MEDICAL PA
Entity type:Organization
Organization Name:ANGLIN MEDICAL PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICKEL
Authorized Official - Middle Name:WRAY
Authorized Official - Last Name:ANGLIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-672-1385
Mailing Address - Street 1:13045 SUMMERFIELD SQUARE DR
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33578-7402
Mailing Address - Country:US
Mailing Address - Phone:813-672-1385
Mailing Address - Fax:813-672-8904
Practice Address - Street 1:13045 SUMMERFIELD SQUARE DR
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33578-7402
Practice Address - Country:US
Practice Address - Phone:813-672-1385
Practice Address - Fax:813-672-8904
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME91647207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
I26305Medicare UPIN