| Burnt Store Family Medicine P L | |
|
100 Madrid Blvd Suite 513 Punta Gorda FL 33950-7968 | |
| (941) 505-0974 | |
| (941) 505-8517 |
| Full Name | Burnt Store Family Medicine P L |
|---|---|
| Speciality | Family Medicine |
| Location | 100 Madrid Blvd, Punta Gorda, Florida |
| Authorized Official Name and Position | Gordon Wang (OWNER) |
| Authorized Official Contact | 9415050974 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Burnt Store Family Medicine P L 100 Madrid Blvd Suite 513 Punta Gorda FL 33950-7968 Ph: (941) 505-0974 | Burnt Store Family Medicine P L 100 Madrid Blvd Suite 513 Punta Gorda FL 33950-7968 Ph: (941) 505-0974 |
| NPI Number | 1164739421 |
|---|---|
| Provider Enumeration Date | 09/08/2010 |
| Last Update Date | 06/23/2011 |
| Medicare PECOS PAC ID | 2365620432 |
|---|---|
| Medicare Enrollment ID | O20110621000489 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1164739421 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207Q00000X | Family Medicine | ME0072508 (Florida) | Primary |
| Provider Name | Gordon Wang |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1174517205 PECOS PAC ID: 1658331848 Enrollment ID: I20041012001445 |
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