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Organization
HEATHROW INTERNAL MEDICINE LLC
Active
Organization
HEATHROW INTERNAL MEDICINE LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. TEDRICK JOHNSON (GROUP VP OPERATIONS)
(407) 333-2273
Entity
Organization
Contact information
Practice address
4106 W LAKE MARY BLVD, SUITE 100, LAKE MARY, FL 32746-3315
(407) 333-2273
(407) 333-3939
Mailing address
4106 W LAKE MARY BLVD, SUITE 100, LAKE MARY, FL 32746-3315
(407) 333-2273
(407) 333-3939
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
—
—
207R00000X
Internal Medicine Physician
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
000617400
—
FL
05
—
307909100
—
FL
01
—
AM199
MEDICARE PTAN
FL
01
—
PTAN DN9084
MEDICARE RAILROAD
FL
Enumeration date
02/14/2008
Last updated
05/28/2014
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