Provider Demographics
NPI:1588086953
Name:MEDI WINTER PARK LLC
Entity type:Organization
Organization Name:MEDI WINTER PARK LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:TRACY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-256-5119
Mailing Address - Street 1:1234 W FAIRBANKS AVE
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-4890
Mailing Address - Country:US
Mailing Address - Phone:407-673-5555
Mailing Address - Fax:
Practice Address - Street 1:1234 W FAIRBANKS AVE
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-4890
Practice Address - Country:US
Practice Address - Phone:407-673-5555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-20
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty