Provider Demographics
NPI:1669981858
Name:DAVITA MEDICAL GROUP FLORIDA CIN
Entity type:Organization
Organization Name:DAVITA MEDICAL GROUP FLORIDA CIN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:
Authorized Official - Last Name:EDGINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-824-0780
Mailing Address - Street 1:10051 5TH ST N STE 200
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33702-2211
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2304 ALOMA AVE
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-3330
Practice Address - Country:US
Practice Address - Phone:407-679-9222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-20
Last Update Date:2017-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty