Provider Demographics
NPI:1588727168
Name:MID-FLORIDA MEDICAL GROUP PA
Entity type:Organization
Organization Name:MID-FLORIDA MEDICAL GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THUMATI
Authorized Official - Middle Name:GURAPPA
Authorized Official - Last Name:JAGALUR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-751-5055
Mailing Address - Street 1:PO BOX 218
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34478-0218
Mailing Address - Country:US
Mailing Address - Phone:352-751-5055
Mailing Address - Fax:352-751-5056
Practice Address - Street 1:910 OLD CAMP RD BLDG 150
Practice Address - Street 2:SUITE 154
Practice Address - City:LADY LAKE
Practice Address - State:FL
Practice Address - Zip Code:32162-5603
Practice Address - Country:US
Practice Address - Phone:352-751-5055
Practice Address - Fax:352-751-5056
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2008-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL31587OtherBCBS
FLDA7068OtherMEDICARE RAILROAD
FLK5084Medicare ID - Type Unspecified