Provider Demographics
NPI:1306174396
Name:IRVIN C. BEMBRY, M.D.P.A.
Entity type:Organization
Organization Name:IRVIN C. BEMBRY, M.D.P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:IRVIN
Authorized Official - Middle Name:C
Authorized Official - Last Name:BEMBRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-792-2985
Mailing Address - Street 1:PO BOX 1028
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:FL
Mailing Address - Zip Code:32052-1028
Mailing Address - Country:US
Mailing Address - Phone:386-792-2985
Mailing Address - Fax:386-792-0833
Practice Address - Street 1:413 5TH AVE NW
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:FL
Practice Address - Zip Code:32052-7801
Practice Address - Country:US
Practice Address - Phone:386-792-2985
Practice Address - Fax:386-792-0833
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-02
Last Update Date:2009-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL22041207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL055712900Medicaid
FL18882OtherBLUE CROSS AND BLUE SHIELD OF FL.
FLD53414Medicare UPIN
FL055712900Medicaid