Provider Demographics
NPI:1174892830
Name:MEDEX PRIMARY CARE
Entity type:Organization
Organization Name:MEDEX PRIMARY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:H
Authorized Official - Last Name:DENNIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-326-0575
Mailing Address - Street 1:6500 CRILL AVE
Mailing Address - Street 2:BUILDING 3 SUTE 1
Mailing Address - City:PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32177-9230
Mailing Address - Country:US
Mailing Address - Phone:386-326-0575
Mailing Address - Fax:386-326-0571
Practice Address - Street 1:6500 CRILL AVE
Practice Address - Street 2:BLDG 3 STE 1
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177-9230
Practice Address - Country:US
Practice Address - Phone:386-326-0575
Practice Address - Fax:386-326-0571
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-23
Last Update Date:2011-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME54477261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care