Provider Demographics
NPI:1871549998
Name:STOCKWELL REISMAN PAULK & TAYLOR PA
Entity type:Organization
Organization Name:STOCKWELL REISMAN PAULK & TAYLOR PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLOTTE
Authorized Official - Middle Name:L
Authorized Official - Last Name:MADANI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-205-8404
Mailing Address - Street 1:2400 MICCOSUKEE RD
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-5314
Mailing Address - Country:US
Mailing Address - Phone:850-877-2105
Mailing Address - Fax:850-216-1321
Practice Address - Street 1:2400 MICCOSUKEE RD
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-5314
Practice Address - Country:US
Practice Address - Phone:850-877-2105
Practice Address - Fax:850-216-1321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL374312800Medicaid
FL24282Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER