Basic Information
| Provider Information | |||||||||
| NPI: | 1629499090 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRO-MED COLLECTORS LLC | ||||||||
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| OtherOrganizationName: | PROMED CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1462 FLANDERS RD | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322071904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043884712 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1907 ATLANTIC BLVD | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322073466 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043884712 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2014 | ||||||||
| LastUpdateDate: | 01/14/2015 | ||||||||
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| AuthorizedOfficialLastName: | BARAKAT | ||||||||
| AuthorizedOfficialFirstName: | HAISSAM | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9049626005 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 208C00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.