Provider Demographics
NPI:1265785869
Name:FANA MEDICAL GROUP, TAMPA RD LLC
Entity type:Organization
Organization Name:FANA MEDICAL GROUP, TAMPA RD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR / OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MIGUEL
Authorized Official - Middle Name:ANTONIO
Authorized Official - Last Name:FANA
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:727-781-5811
Mailing Address - Street 1:2626 TAMPA ROAD, SUITE #202
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34684
Mailing Address - Country:US
Mailing Address - Phone:727-781-5811
Mailing Address - Fax:727-781-5613
Practice Address - Street 1:2626 TAMPA ROAD, SUITE 202
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34684
Practice Address - Country:US
Practice Address - Phone:727-781-5811
Practice Address - Fax:727-781-5613
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-19
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME80639207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL259988100Medicaid
FLH22163Medicare UPIN