Provider Demographics
NPI:1447290952
Name:PHYSICIAN PARTNERS NETWORK PA
Entity type:Organization
Organization Name:PHYSICIAN PARTNERS NETWORK PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LOUISE
Authorized Official - Middle Name:
Authorized Official - Last Name:ELDRIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-796-9990
Mailing Address - Street 1:605 LAMAR AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34601-3211
Mailing Address - Country:US
Mailing Address - Phone:352-796-9990
Mailing Address - Fax:352-796-2226
Practice Address - Street 1:605 LAMAR AVE
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34601-3211
Practice Address - Country:US
Practice Address - Phone:352-796-9990
Practice Address - Fax:352-796-2226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-07
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL208D00000X, 261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL40952OtherBLUE CROSS BLUE SHIELD
FLCD8188OtherRAILROAD MEDICARE
FL251473700Medicaid
FL660024700Medicaid
FL660024700Medicaid
FLCD8188OtherRAILROAD MEDICARE