Provider Demographics
NPI:1386799542
Name:HAINES CITY INTERNAL MEDICINE PA
Entity type:Organization
Organization Name:HAINES CITY INTERNAL MEDICINE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PART OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:C
Authorized Official - Last Name:STINE
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:863-422-9562
Mailing Address - Street 1:608 INGRAHAM AVENUE
Mailing Address - Street 2:
Mailing Address - City:HAINES CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33844-5619
Mailing Address - Country:US
Mailing Address - Phone:863-422-9562
Mailing Address - Fax:863-421-3246
Practice Address - Street 1:608 INGRAHAM AVE
Practice Address - Street 2:
Practice Address - City:HAINES CITY
Practice Address - State:FL
Practice Address - Zip Code:33844-4330
Practice Address - Country:US
Practice Address - Phone:863-422-9562
Practice Address - Fax:863-421-3246
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2020-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0050219207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL259269000Medicaid
FLK1910Medicare PIN