Provider Demographics
NPI:1285812362
Name:MAITLAND AVENUE URGENT CARE PA
Entity type:Organization
Organization Name:MAITLAND AVENUE URGENT CARE PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SETH
Authorized Official - Middle Name:T
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:321-207-0002
Mailing Address - Street 1:411 MAITLAND AVE
Mailing Address - Street 2:SUITE 1002
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32701-5448
Mailing Address - Country:US
Mailing Address - Phone:321-207-0002
Mailing Address - Fax:321-207-0003
Practice Address - Street 1:411 MAITLAND AVE STE 1002
Practice Address - Street 2:
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32701-5448
Practice Address - Country:US
Practice Address - Phone:321-207-0002
Practice Address - Fax:321-207-2003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-31
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS5330261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL051599000Medicaid
FLC68470Medicare UPIN