Provider Demographics
NPI:1386715480
Name:PHYSICIAN PARTNERS NETWORK PA
Entity type:Organization
Organization Name:PHYSICIAN PARTNERS NETWORK PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HUSAM
Authorized Official - Middle Name:
Authorized Official - Last Name:ABUZARAD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-596-4657
Mailing Address - Street 1:11373 CORTEZ BLVD
Mailing Address - Street 2:SUITE 304
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34613-5414
Mailing Address - Country:US
Mailing Address - Phone:352-597-8994
Mailing Address - Fax:352-597-8901
Practice Address - Street 1:11373 CORTEZ BLVD
Practice Address - Street 2:SUITE 304
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34613-5414
Practice Address - Country:US
Practice Address - Phone:352-597-8994
Practice Address - Fax:352-597-8901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-11
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X, 207RE0101X, 363AM0700X
FL261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL251473700Medicaid
FL40952OtherBLUE CROSS
FLCD8188OtherRAILROAD MEDICARE
FL103894Medicare Oscar/Certification
FL40952Medicare PIN