Provider Demographics
NPI:1245307917
Name:RAY C WUNDERLICH JR M.D. P.A.
Entity type:Organization
Organization Name:RAY C WUNDERLICH JR M.D. P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING COMPANY OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL LYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:SWEENEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-391-1257
Mailing Address - Street 1:8821 DR MARTIN LUTHER KING JR ST N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33702-3443
Mailing Address - Country:US
Mailing Address - Phone:727-822-3612
Mailing Address - Fax:727-578-1370
Practice Address - Street 1:8821 DR MARTIN LUTHER KING JR ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33702-3443
Practice Address - Country:US
Practice Address - Phone:727-822-3612
Practice Address - Fax:727-578-1370
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK0726Medicare ID - Type Unspecified