Provider Demographics
NPI:1952710147
Name:BRANDON PSYCHIATRIC GROUP LLC
Entity Type:Organization
Organization Name:BRANDON PSYCHIATRIC GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HANY
Authorized Official - Middle Name:BOTROS
Authorized Official - Last Name:MIKHAIL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-923-6025
Mailing Address - Street 1:PO BOX 1584
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30028-1584
Mailing Address - Country:US
Mailing Address - Phone:678-923-6025
Mailing Address - Fax:813-413-6660
Practice Address - Street 1:106 W WINDHORST RD
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33510-2455
Practice Address - Country:US
Practice Address - Phone:678-923-6025
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-13
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL953512084B0040X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084B0040XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyBehavioral Neurology & NeuropsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL275940302Medicaid
AD108AMedicare PIN