Provider Demographics
NPI:1992785513
Name:MY DOCTOR PA
Entity type:Organization
Organization Name:MY DOCTOR PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:TRACY
Authorized Official - Last Name:HARLAND
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:561-992-8000
Mailing Address - Street 1:1200 S MAIN ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BELLE GLADE
Mailing Address - State:FL
Mailing Address - Zip Code:33430-7808
Mailing Address - Country:US
Mailing Address - Phone:561-992-8000
Mailing Address - Fax:561-992-8020
Practice Address - Street 1:1200 S MAIN ST
Practice Address - Street 2:SUITE 200
Practice Address - City:BELLE GLADE
Practice Address - State:FL
Practice Address - Zip Code:33430-7808
Practice Address - Country:US
Practice Address - Phone:561-992-8000
Practice Address - Fax:561-992-8020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-19
Last Update Date:2011-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS-0005579207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL253267100Medicaid
FLEJ549ZMedicare PIN
FL253267100Medicaid
FL21281AMedicare PIN
FLE3128ZMedicare PIN