Provider Demographics
NPI:1386063592
Name:DR. BORIS KAWLICHE
Entity type:Organization
Organization Name:DR. BORIS KAWLICHE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BORIS
Authorized Official - Middle Name:L
Authorized Official - Last Name:KAWLICHE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-681-5880
Mailing Address - Street 1:401 N PARSONS AVE
Mailing Address - Street 2:SUITE 107A
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33510-4538
Mailing Address - Country:US
Mailing Address - Phone:813-681-5880
Mailing Address - Fax:813-681-5958
Practice Address - Street 1:401 N PARSONS AVE
Practice Address - Street 2:SUITE 107A
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33510-4538
Practice Address - Country:US
Practice Address - Phone:813-681-5880
Practice Address - Fax:813-681-5958
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-15
Last Update Date:2014-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME665002084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL378031700Medicaid
FL378031700Medicaid