Provider Demographics
NPI:1336189190
Name:FAMILY PRACTICE-ST CLOUD, INC.
Entity Type:Organization
Organization Name:FAMILY PRACTICE-ST CLOUD, INC.
Other - Org Name:PROHEALTH FAMILY PHYSICIANS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:FREDERICK
Authorized Official - Last Name:WILKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-892-0009
Mailing Address - Street 1:3100 17TH ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34769-6021
Mailing Address - Country:US
Mailing Address - Phone:407-892-0009
Mailing Address - Fax:407-892-3285
Practice Address - Street 1:3100 17TH ST
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:FL
Practice Address - Zip Code:34769-6021
Practice Address - Country:US
Practice Address - Phone:407-892-0009
Practice Address - Fax:407-892-3285
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-08
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0036943207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL34984OtherBLUE CROSS BLUE SHEILD
FLK4927Medicare ID - Type Unspecified