Provider Demographics
NPI:1184701740
Name:FAMILY PHYSICIAN GROUP
Entity type:Organization
Organization Name:FAMILY PHYSICIAN GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HOSPITALIST
Authorized Official - Prefix:
Authorized Official - First Name:VIJAYALAKSHMI
Authorized Official - Middle Name:
Authorized Official - Last Name:POLAVARAPU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-281-1755
Mailing Address - Street 1:3391 S KIRKMAN RD
Mailing Address - Street 2:APT #1223
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32811-1943
Mailing Address - Country:US
Mailing Address - Phone:407-822-4350
Mailing Address - Fax:
Practice Address - Street 1:6320 OLD WINTER GARDEN RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32835-1381
Practice Address - Country:US
Practice Address - Phone:407-822-4350
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME#91019282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLI 17225Medicare UPIN
FLU3232YMedicare ID - Type Unspecified