Provider Demographics
NPI:1295938785
Name:WILLISTON FAMILY PRACTICE,PA
Entity type:Organization
Organization Name:WILLISTON FAMILY PRACTICE,PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICEMANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ERICA
Authorized Official - Middle Name:NATASHA
Authorized Official - Last Name:MCBRIDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-529-1111
Mailing Address - Street 1:111 W NOBLE AVE
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:FL
Mailing Address - Zip Code:32696-2027
Mailing Address - Country:US
Mailing Address - Phone:352-529-1111
Mailing Address - Fax:352-529-1115
Practice Address - Street 1:111 W NOBLE AVE
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:FL
Practice Address - Zip Code:32696-2027
Practice Address - Country:US
Practice Address - Phone:352-529-1111
Practice Address - Fax:352-529-1115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-11
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL108965Medicare ID - Type UnspecifiedMEDICAREA