Provider Demographics
NPI:1720249410
Name:SHIRLEY A ICE MD PA
Entity Type:Organization
Organization Name:SHIRLEY A ICE MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:A
Authorized Official - Last Name:ICE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-465-2449
Mailing Address - Street 1:19204 E PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:DUNNELLON
Mailing Address - State:FL
Mailing Address - Zip Code:34432-6111
Mailing Address - Country:US
Mailing Address - Phone:352-465-2449
Mailing Address - Fax:352-465-2451
Practice Address - Street 1:19204 E PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:DUNNELLON
Practice Address - State:FL
Practice Address - Zip Code:34432-6111
Practice Address - Country:US
Practice Address - Phone:352-465-2449
Practice Address - Fax:352-465-2451
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-24
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0071113207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2532203400Medicaid
FL2532203400Medicaid
DM022AMedicare PIN