Provider Demographics
NPI:1316902539
Name:PRIMARY URGENT CARE PL
Entity type:Organization
Organization Name:PRIMARY URGENT CARE PL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:B
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:941-480-0500
Mailing Address - Street 1:1370 E VENICE AVE
Mailing Address - Street 2:202
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34285-9082
Mailing Address - Country:US
Mailing Address - Phone:941-480-0500
Mailing Address - Fax:941-480-9322
Practice Address - Street 1:1370 E VENICE AVE
Practice Address - Street 2:202
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34285-9082
Practice Address - Country:US
Practice Address - Phone:941-480-0500
Practice Address - Fax:941-480-9322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-19
Last Update Date:2010-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL98726OtherBCBS
FLDE0506OtherRR MEDICARE
FL98726OtherBCBS
FL=========OtherTAX ID