Provider Demographics
NPI:1194711044
Name:FLORIDA MEDICAL OBSERVATION ASSOCIATES, PA
Entity type:Organization
Organization Name:FLORIDA MEDICAL OBSERVATION ASSOCIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-875-8784
Mailing Address - Street 1:1051 WINDERLEY PL
Mailing Address - Street 2:SUITE 103
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-7269
Mailing Address - Country:US
Mailing Address - Phone:407-875-8784
Mailing Address - Fax:
Practice Address - Street 1:601 E ROLLINS ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-1248
Practice Address - Country:US
Practice Address - Phone:407-303-5600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical ServicesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK5446Medicare ID - Type Unspecified