Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | OS4043 | FL |
N | 207QH0002X | Family Doctor - Hospice and Palliative Medicine | OS4043 | FL |
NPI | 1366624827 |
---|---|
Provider Name | Philip Richard Wirt III |
First Address | Inverness, FL 34453-1707 |
Second Address | Inverness, FL 34453-1707 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 27/11/2007 |
Last Update Date | 27/11/2007 |