Ellenton Family Practice Direct PLLC
Organization Active NPI Family Medicine Physician · Ellenton, FL
NPI 1124471503 · NPPES record last updated Mar 7, 2023
Key facts
- NPI
- 1124471503
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Family Medicine Physician 207Q00000X
- License
- PA9102767 (FL)
- Legal business name
- ELLENTON FAMILY PRACTICE DIRECT PLLC
- Practice address
- 907 25TH Dr E
Ellenton, FL 34222-2053 - Phone
- (941) 321-8299
- NPI assigned
- Jul 20, 2016
- Organization subpart
- No
Authorized official
- Name
- Mr. David Allan Hervig, PA-C
- Title
- Office Manage and Partner
- Phone
- (941) 730-5326
Practitioners 4
-
Stephanie Marie Arreola, RN, ARNP, AGPCNP-C
-
Raphael Kulawik, D.O.
-
David Hervig, PA-C
-
Lauren S Swanson, APRN FNP-C
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 10D2123741 | Ellenton Family Practice Direct | Certificate of waiver | Dec 29, 2026 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in FL
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20171228002269 | FL | Part B Supplier - Clinic/Group Practice | 1052679768 |
Receives reassigned benefits from 3 practitioners Practice locations: Ellenton, FL |
National Provider Directory
Locations
907 25th Dr E
Ellenton, FL 34222
Phone (941) 417-7386
Interoperability endpoints
- https://api.platform.athenahealth.com/13889/brand/1/csg/1/fhir/r4
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician |
207Q00000X | PA9102767 | FL | Yes |
Addresses
Primary practice location
907 25TH Dr E
Ellenton, FL 34222-2053
Mailing address
907 25TH Dr E
Ellenton, FL 34222-2053
Phone (941) 417-7386
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| OS12316 | Other | FL | LICENSE |
Other providers in Ellenton, FL
- Dominica M. Rivera LLC
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- Dr. Tre Thomas, Psychologist, PLLC
- Elite Integrated Medical Centers
- Ellenton Family Dental Corp
- Ellenton Pediatrics PA
- Em Legacy LLC
- Rebecca L Emmett
- Excel Pain and Spine LLC
- Faipler Chiropractic LLC
All providers in Ellenton, FL · Family Medicine Physician in Florida
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Mar 7, 2023. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.