Provider Demographics
NPI:1316977259
Name:APOPKA MEDICAL GROUP PA
Entity type:Organization
Organization Name:APOPKA MEDICAL GROUP PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:INGRID
Authorized Official - Middle Name:
Authorized Official - Last Name:BEHNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-886-1171
Mailing Address - Street 1:PO BOX 1107
Mailing Address - Street 2:
Mailing Address - City:APOPKA
Mailing Address - State:FL
Mailing Address - Zip Code:32704-1107
Mailing Address - Country:US
Mailing Address - Phone:407-886-1171
Mailing Address - Fax:407-886-8386
Practice Address - Street 1:125 S PARK AVE
Practice Address - Street 2:
Practice Address - City:APOPKA
Practice Address - State:FL
Practice Address - Zip Code:32703-4254
Practice Address - Country:US
Practice Address - Phone:407-886-1171
Practice Address - Fax:407-886-8386
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0055219173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL037621300Medicaid
FL037621300Medicaid
FL08685Medicare PIN