Provider Demographics
NPI:1649383720
Name:SPACECOAST INTERNAL MEDICINE AND GERITRIC CORP
Entity type:Organization
Organization Name:SPACECOAST INTERNAL MEDICINE AND GERITRIC CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FAIAZ
Authorized Official - Middle Name:M
Authorized Official - Last Name:RASUL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-639-4243
Mailing Address - Street 1:PO BOX 549
Mailing Address - Street 2:
Mailing Address - City:SHARPES
Mailing Address - State:FL
Mailing Address - Zip Code:32959-0549
Mailing Address - Country:US
Mailing Address - Phone:321-639-4243
Mailing Address - Fax:321-639-4266
Practice Address - Street 1:990 PALM ST
Practice Address - Street 2:
Practice Address - City:COCOA
Practice Address - State:FL
Practice Address - Zip Code:32927-5145
Practice Address - Country:US
Practice Address - Phone:321-639-4243
Practice Address - Fax:321-639-4266
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2011-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME72416207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL251377300Medicaid
FL32700OtherBCBS
FL32700BMedicare PIN
FL251377300Medicaid