| Olympia Medical Group, Llc | |
|
2306 North Blvd W Ste C Davenport FL 33837-8976 | |
| (863) 547-9200 | |
| Not Available |
| Full Name | Olympia Medical Group, Llc |
|---|---|
| Speciality | Family Medicine |
| Location | 2306 North Blvd W Ste C, Davenport, Florida |
| Authorized Official Name and Position | Bala Kode (MANAGING PARTNER) |
| Authorized Official Contact | 8635479200 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Olympia Medical Group, Llc 2306 North Blvd W Ste C Davenport FL 33837-8976 Ph: () - | Olympia Medical Group, Llc 2306 North Blvd W Ste C Davenport FL 33837-8976 Ph: (863) 547-9200 |
| NPI Number | 1013473495 |
|---|---|
| Provider Enumeration Date | 02/11/2019 |
| Last Update Date | 12/22/2023 |
| Medicare PECOS PAC ID | 9830525880 |
|---|---|
| Medicare Enrollment ID | O20200211000563 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1013473495 | NPI | - | NPPES |
| 105446600 | Medicaid | FL | |
| HCC11921 | Other | FL | CLINIC LICENSE |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207Q00000X | Family Medicine | (* (Not Available)) | Primary |
| Provider Name | Mahnaz Qayyum |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1457338519 PECOS PAC ID: 5193780856 Enrollment ID: I20041123000103 |
| Provider Name | Rocio Labrada |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1154923290 PECOS PAC ID: 0143634873 Enrollment ID: I20210120002928 |
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