Provider Demographics
NPI:1528111085
Name:CENTRAL FLORIDA MEDICAL ASSOCIATES, INC
Entity type:Organization
Organization Name:CENTRAL FLORIDA MEDICAL ASSOCIATES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ILENE
Authorized Official - Middle Name:
Authorized Official - Last Name:BALLENTINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-774-0401
Mailing Address - Street 1:2555 S VOLUSIA AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32763-9135
Mailing Address - Country:US
Mailing Address - Phone:386-774-0401
Mailing Address - Fax:386-774-5783
Practice Address - Street 1:2555 S VOLUSIA AVE
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-9135
Practice Address - Country:US
Practice Address - Phone:386-774-0401
Practice Address - Fax:386-774-5783
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME75141207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK2371OtherMEDICARE PTAN