Provider Demographics
NPI: | 1831862515 |
---|---|
Name: | FWC UROGYNECOLOGY, LLC |
Entity type: | Organization |
Organization Name: | FWC UROGYNECOLOGY, LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | MANAGER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | ERICA |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | HERNANDEZ |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 561-300-2410 |
Mailing Address - Street 1: | PO BOX 5556 |
Mailing Address - Street 2: | |
Mailing Address - City: | BELFAST |
Mailing Address - State: | ME |
Mailing Address - Zip Code: | 04915-5500 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 561-300-2410 |
Mailing Address - Fax: | 561-235-7292 |
Practice Address - Street 1: | 2801 SE 1ST AVE STE 101 |
Practice Address - Street 2: | |
Practice Address - City: | OCALA |
Practice Address - State: | FL |
Practice Address - Zip Code: | 34471-0478 |
Practice Address - Country: | US |
Practice Address - Phone: | 352-690-6300 |
Practice Address - Fax: | 352-690-6802 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | Yes |
Parent Organization LBN: | FWC UROGYNECOLOGY, LLC |
Parent Organization TIN: | <UNAVAIL> |
Enumeration Date: | 2021-07-28 |
Last Update Date: | 2022-02-23 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 2088F0040X | Allopathic & Osteopathic Physicians | Urology | Urogynecology and Reconstructive Pelvic Surgery | Group - Multi-Specialty |