Provider Demographics
NPI:1063546133
Name:PREVENTIVE MEDICINE CTR OF GAINESVILLE INC
Entity type:Organization
Organization Name:PREVENTIVE MEDICINE CTR OF GAINESVILLE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:ERICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-331-5138
Mailing Address - Street 1:905 NW 56TH TERRACE
Mailing Address - Street 2:SUITE B
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32605
Mailing Address - Country:US
Mailing Address - Phone:352-331-5138
Mailing Address - Fax:352-331-9399
Practice Address - Street 1:905 NW 56TH TERRACE
Practice Address - Street 2:SUITE B
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32605
Practice Address - Country:US
Practice Address - Phone:352-331-5138
Practice Address - Fax:352-331-9399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME22324OtherSTATE ID
FLME22324OtherSTATE ID