Provider Demographics
NPI:1306068606
Name:TAGRID ADILI MD PA
Entity type:Organization
Organization Name:TAGRID ADILI MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TAGRID
Authorized Official - Middle Name:
Authorized Official - Last Name:ADILI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:772-807-7166
Mailing Address - Street 1:463 NW PRIMA VISTA BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983
Mailing Address - Country:US
Mailing Address - Phone:772-807-7166
Mailing Address - Fax:772-807-7169
Practice Address - Street 1:463 NW PRIMA VISTA BLVD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34983
Practice Address - Country:US
Practice Address - Phone:772-807-7166
Practice Address - Fax:772-807-7169
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0067274174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
26511ZMedicare PIN
G22352Medicare UPIN