Provider Demographics
NPI:1457523003
Name:INSTITUTE OF INTERNAL MEDICINE P A
Entity Type:Organization
Organization Name:INSTITUTE OF INTERNAL MEDICINE P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CARMEN
Authorized Official - Middle Name:C
Authorized Official - Last Name:VIVERO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-460-0707
Mailing Address - Street 1:1301 PLANTATION ISLAND DR S
Mailing Address - Street 2:STE 402-B
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080-3108
Mailing Address - Country:US
Mailing Address - Phone:904-460-0707
Mailing Address - Fax:
Practice Address - Street 1:1301 PLANTATION ISLAND DR S
Practice Address - Street 2:STE 402B
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32080-3108
Practice Address - Country:US
Practice Address - Phone:904-460-0707
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-24
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME76599207R00000X, 207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDN9360OtherRR MEDICARE
FL44784OtherBCBS
FL003271700Medicaid
FL44784OtherBCBS
FL003271700Medicaid