Provider Demographics
NPI:1699954057
Name:FLORIDA EAST COAST MEDICAL GROUP INC
Entity type:Organization
Organization Name:FLORIDA EAST COAST MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:V-P/CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:DMITRY
Authorized Official - Middle Name:
Authorized Official - Last Name:MISHELEVICH
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:863-763-6496
Mailing Address - Street 1:1107 N PARROTT AVE
Mailing Address - Street 2:
Mailing Address - City:OKEECHOBEE
Mailing Address - State:FL
Mailing Address - Zip Code:34972-2128
Mailing Address - Country:US
Mailing Address - Phone:863-763-6496
Mailing Address - Fax:863-763-1965
Practice Address - Street 1:1107 N PARROTT AVE
Practice Address - Street 2:
Practice Address - City:OKEECHOBEE
Practice Address - State:FL
Practice Address - Zip Code:34972
Practice Address - Country:US
Practice Address - Phone:863-763-5122
Practice Address - Fax:863-763-1965
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-01
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty