Provider Demographics
NPI:1871798587
Name:CONVENIENT WALK IN MEDICAL CLINIC INC
Entity type:Organization
Organization Name:CONVENIENT WALK IN MEDICAL CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CLUKIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-659-2502
Mailing Address - Street 1:1611 E SHELL POINT RD
Mailing Address - Street 2:
Mailing Address - City:RUSKIN
Mailing Address - State:FL
Mailing Address - Zip Code:33570-5087
Mailing Address - Country:US
Mailing Address - Phone:813-659-2502
Mailing Address - Fax:813-659-2584
Practice Address - Street 1:1611 E SHELL POINT RD
Practice Address - Street 2:
Practice Address - City:RUSKIN
Practice Address - State:FL
Practice Address - Zip Code:33570-5087
Practice Address - Country:US
Practice Address - Phone:813-659-2502
Practice Address - Fax:813-659-2584
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-21
Last Update Date:2007-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME31419207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL79188AMedicare ID - Type Unspecified
FLD27235Medicare UPIN