| Four Corners Internal Medicine, LLC | |
|
106 Polo Park East Blvd Davenport FL 33897-9407 | |
| (863) 424-8900 | |
| (863) 424-8823 |
| Full Name | Four Corners Internal Medicine, LLC |
|---|---|
| Speciality | Clinic/Center |
| Location | 106 Polo Park East Blvd, Davenport, Florida |
| Authorized Official Name and Position | Srinath Reddy Kosanam (OWNER) |
| Authorized Official Contact | 8634248900 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Four Corners Internal Medicine, LLC 10603 Emerald Chase Dr Orlando FL 32836-5855 Ph: (407) 217-5353 | Four Corners Internal Medicine, LLC 106 Polo Park East Blvd Davenport FL 33897-9407 Ph: (863) 424-8900 |
| NPI Number | 1346295466 |
|---|---|
| Provider Enumeration Date | 05/24/2006 |
| Last Update Date | 10/20/2010 |
| Medicare PECOS PAC ID | 6305857517 |
|---|---|
| Medicare Enrollment ID | O20060531000090 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1346295466 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261Q00000X | Clinic/center | ME78339 (Florida) | Primary |
| Provider Name | Srinath Reddy Kosanam |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1154313476 PECOS PAC ID: 4486665692 Enrollment ID: I20060601000069 |
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