Provider Demographics
NPI:1215099007
Name:FAMILY MEDICAL GROUP PA
Entity type:Organization
Organization Name:FAMILY MEDICAL GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JOANNE
Authorized Official - Middle Name:E
Authorized Official - Last Name:STAYTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-465-7010
Mailing Address - Street 1:113 HEALTH WAY
Mailing Address - Street 2:
Mailing Address - City:LAKE PLACID
Mailing Address - State:FL
Mailing Address - Zip Code:33852-8123
Mailing Address - Country:US
Mailing Address - Phone:863-465-7010
Mailing Address - Fax:
Practice Address - Street 1:113 HEALTH WAY
Practice Address - Street 2:
Practice Address - City:LAKE PLACID
Practice Address - State:FL
Practice Address - Zip Code:33852-8123
Practice Address - Country:US
Practice Address - Phone:863-465-7010
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FAMILY MEDICAL GROUP PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-15
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL660046800Medicaid
FL660129400Medicaid
FL45269OtherBCBSFL
FL660219300Medicaid
FL103857Medicare Oscar/Certification
FL103879Medicare Oscar/Certification
FLK1773AMedicare PIN
FLK1773Medicare PIN
FL660046800Medicaid