Basic Information
| Provider Information | |||||||||
| NPI: | 1003002759 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOBILE PHYSICIAN SERVICES INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6804 CECELIA DR | ||||||||
| Address2: | |||||||||
| City: | NEW PORT RICHEY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346534935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8552320644 | ||||||||
| FaxNumber: | 8885460488 | ||||||||
| Practice Location | |||||||||
| Address1: | 6804 CECELIA DR | ||||||||
| Address2: | |||||||||
| City: | NEW PORT RICHEY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346534935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7272320644 | ||||||||
| FaxNumber: | 8885460488 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2007 | ||||||||
| LastUpdateDate: | 02/18/2021 | ||||||||
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| AuthorizedOfficialLastName: | WACKSMAN | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8552320644 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 02/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 152W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | 207R00000X | ME0086161 | FL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 2084P0805X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Geriatric Psychiatry | 213ES0103X | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 207RH0002X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hospice and Palliative Medicine |
ID Information
| ID | Type | State | Issuer | Description | K9757 | 01 | FL | PTAN | OTHER | K9757A | 01 | FL | FL PTAN | OTHER | MEDICARE NPI | 01 | FL | 1003002759 | OTHER | 007870000 | 05 | FL | MEDICAID | 0404354 | 05 | OH | MEDICAID | 000MQ | 01 | FL | BCBS GROUP | OTHER |