Provider Demographics
NPI:1306879721
Name:INTERNAL MEDICINE GROUP OF WINTER HAVEN,P.A.
Entity type:Organization
Organization Name:INTERNAL MEDICINE GROUP OF WINTER HAVEN,P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:D
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-294-4404
Mailing Address - Street 1:400 AVENUE K SE
Mailing Address - Street 2:SUITE 11
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33880-4146
Mailing Address - Country:US
Mailing Address - Phone:863-294-4404
Mailing Address - Fax:863-294-1059
Practice Address - Street 1:400 AVENUE K SE
Practice Address - Street 2:SUITE 11
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33880-4146
Practice Address - Country:US
Practice Address - Phone:863-294-4404
Practice Address - Fax:863-294-1059
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2013-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL253257300Medicaid
FL253257300Medicaid