Provider Demographics
NPI:1205278454
Name:MEDICAL & PSYCHIATRIC INSITIUTE OF FLORIDA, INC.
Entity type:Organization
Organization Name:MEDICAL & PSYCHIATRIC INSITIUTE OF FLORIDA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ASAD
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-216-4000
Mailing Address - Street 1:927 BEVILLE RD STE 7
Mailing Address - Street 2:
Mailing Address - City:SOUTH DAYTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32119-1769
Mailing Address - Country:US
Mailing Address - Phone:386-269-9009
Mailing Address - Fax:386-269-9004
Practice Address - Street 1:6056 CENTRAL PARK BLVD
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-9539
Practice Address - Country:US
Practice Address - Phone:304-216-4000
Practice Address - Fax:386-676-2555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-29
Last Update Date:2014-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1145282084F0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic PsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0116181000Medicaid
OH0206560Medicaid