Family Medical Group PA

Primary specialty

Family Medicine PhysicianTaxonomy code 207Q00000X

Legal business name

FAMILY MEDICAL GROUP PA

Practice address

113 Health Way
Lake Placid, FL 33852-8123

Phone

(863) 465-7010

NPI assigned

Dec 15, 2006

Organization subpart

Yes

Parent organization

FAMILY MEDICAL GROUP PAAs reported in NPPES

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

• Wilfredo Corredera, M.D.

  • Family Medicine Physician
  • Lake Placid, FL
  • NPI 1891743365

  5% Or Greater Direct Ownership Interest, Corporate Director, General Partnership Interest

  CMS ownership
• Daniel E Montero, M.D.

  • Family Medicine Physician
  • Sebring, FL
  • NPI 1376591842

  5% Or Greater Direct Ownership Interest, Corporate Director, General Partnership Interest

  CMS ownership

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• William John Gill, PA

  • Medical Physician Assistant
  • Wauchula, FL
  • NPI 1427164334
  NPD (past)
• Mary Jean Gossman, MPAS, PA-C

  • Physician Assistant
  • High Springs, FL
  • NPI 1225083082
  NPD (past)
• Kendra Sue Hall-Franks, DO

  • Family Medicine Physician
  • Lakeland, FL
  • NPI 1164438859

  Family Medicine

  NPD (past)
• Donna S Perkins, ARNP

  • Nurse Practitioner
  • Babson Park, FL
  • NPI 1053369553
  NPD (past)
• Gordon Neal Williford, PA-C

  • Medical Physician Assistant
  • Sebring, FL
  • NPI 1235128380
  NPD (past)

Medicare fee-for-service enrollment

Enrolled in FL

Enrollment records 1

Rural health clinic certification: CCN 103884

Legal name

FAMILY MEDICAL GROUP PA

Certification status

Active

Provider type (POS)

Rural health clinic

Participating since

Nov 23, 1994

Last certification

Jul 19, 2021

Ownership / control type

1B

Organization structure

CorporationProprietary

Incorporated

Oct 1, 2002 in FL

Enrollment address

3420 US Highway 27 N
Sebring, FL 33870-1637

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

Part of

Richrd a Campbell MD

Locations

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Joanne E Stayton

Title

Practice Administrator

Phone

(863) 465-7010

Specialties & licenses 1

Addresses

Other identifiers 4

The complete record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1166140800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1621814400000",
    "number": "1215099007",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "113 HEALTH WAY",
            "city": "LAKE PLACID",
            "state": "FL",
            "postal_code": "338528123",
            "telephone_number": "863-465-7010"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "113 HEALTH WAY",
            "city": "LAKE PLACID",
            "state": "FL",
            "postal_code": "338528123",
            "telephone_number": "863-465-7010"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FAMILY MEDICAL GROUP PA",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "FAMILY MEDICAL GROUP PA",
        "enumeration_date": "2006-12-15",
        "last_updated": "2021-05-24",
        "certification_date": "2021-05-11",
        "status": "A",
        "authorized_official_last_name": "STAYTON",
        "authorized_official_first_name": "JOANNE",
        "authorized_official_middle_name": "E",
        "authorized_official_title_or_position": "PRACTICE ADMINISTRATOR",
        "authorized_official_telephone_number": "863-465-7010"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "660046800",
            "state": "FL"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "660129400",
            "state": "FL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBSFL",
            "identifier": "45269",
            "state": "FL"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "660219300",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Scott Earley, LMHC
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• Javier Leandro Fernandez, PT
• Carly Delbert Fioramanti, APRN
• Eduardo Enrique Florez
• Florida Community Home Care Services LLC
• Florida Radiology Management LLC

• All providers in Lake Placid, FL
• Family Medicine Physician in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 24, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.