Provider Demographics
NPI:1093448102
Name:INCHARGECLINIC
Entity type:Organization
Organization Name:INCHARGECLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MMGR
Authorized Official - Prefix:
Authorized Official - First Name:JILL
Authorized Official - Middle Name:
Authorized Official - Last Name:MARSHALL-ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:APRN CWS FACCWS
Authorized Official - Phone:813-530-9666
Mailing Address - Street 1:12250 BLUE PACIFIC DR
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33579-1803
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:813-336-8789
Practice Address - Street 1:12250 BLUE PACIFIC DR
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33579-1803
Practice Address - Country:US
Practice Address - Phone:813-955-9734
Practice Address - Fax:813-366-8789
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-06
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
No173000000XOther Service ProvidersLegal MedicineGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1205877560Medicaid