Provider Demographics
NPI:1104064245
Name:AUDWIN B NELSON MD P A
Entity type:Organization
Organization Name:AUDWIN B NELSON MD P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AUDWIN
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:863-471-2320
Mailing Address - Street 1:4215 SUN N LAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:SEBRING
Mailing Address - State:FL
Mailing Address - Zip Code:33872-2158
Mailing Address - Country:US
Mailing Address - Phone:863-471-2320
Mailing Address - Fax:863-471-2101
Practice Address - Street 1:4215 SUN N LAKE BLVD
Practice Address - Street 2:
Practice Address - City:SEBRING
Practice Address - State:FL
Practice Address - Zip Code:33872-2158
Practice Address - Country:US
Practice Address - Phone:863-471-2320
Practice Address - Fax:863-471-2101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-28
Last Update Date:2010-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME86834207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL266302300Medicaid
FLBN716AMedicare PIN