Provider Demographics
NPI:1801263983
Name:HEALTHY FAMILY MEDICAL GROUP, LLC
Entity type:Organization
Organization Name:HEALTHY FAMILY MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:JULIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BERESFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:340-642-3813
Mailing Address - Street 1:PO BOX 891293
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33689-1100
Mailing Address - Country:US
Mailing Address - Phone:813-393-1500
Mailing Address - Fax:813-393-1501
Practice Address - Street 1:1138 NIKKI VIEW DR
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-4868
Practice Address - Country:US
Practice Address - Phone:813-393-1500
Practice Address - Fax:813-393-1501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-25
Last Update Date:2016-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL94636208000000X
FLACN415207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty