| Entity Name: | INDEPENDENT MULTISPECIALTY GROUP OF FLORIDA, LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Active |
| Date Filed: | 02 Feb 2018 (7 years ago) |
| Last Event: | LC STMNT OF RA/RO CHG |
| Event Date Filed: | 13 Dec 2018 (6 years ago) |
| Document Number: | L18000030203 |
| FEI/EIN Number | 32-0558407 |
| Address: | 1447 MEDICAL PARK BLVD, WELLINGTON, FL, 33414, US |
| Mail Address: | 1447 MEDICAL PARK BLVD, WELLINGTON, FL, 33414, US |
| ZIP code: | 33414 |
| County: | Palm Beach |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1346745122 | 2018-03-26 | 2023-08-08 | 1447 MEDICAL PARK BLVD STE 405, WELLINGTON, FL, 334143183, US | 1447 MEDICAL PARK BLVD STE 405, WELLINGTON, FL, 334143183, US | |||||||||||||||||||||||||||||||||||||
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| Phone | +1 904-334-0910 |
| Fax | 5613632597 |
Authorized person
| Name | DR. SRIINIVAS KAZA |
| Role | OWNER |
| Phone | 5617678342 |
Taxonomy
| Taxonomy Code | 207RB0002X - Obesity Medicine (Internal Medicine) Physician |
| Is Primary | No |
| Taxonomy Code | 2084N0400X - Neurology Physician |
| Is Primary | No |
| Taxonomy Code | 208600000X - Surgery Physician |
| Is Primary | Yes |
| Taxonomy Code | 2086X0206X - Surgical Oncology Physician |
| Is Primary | No |
| Taxonomy Code | 208G00000X - Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician |
| Is Primary | No |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 100453300 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| BRANCIFORTE LAUREN M | Agent | 1447 MEDICAL PARK BLVD, WELLINGTON, FL, 33414 |
| Name | Role | Address |
|---|---|---|
| branciforte lauren | Manager | 1447 MEDICAL PARK BLVD, WELLINGTON, FL, 33414 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| REGISTERED AGENT ADDRESS CHANGED | 2024-02-06 | 1447 MEDICAL PARK BLVD, STE 405, WELLINGTON, FL 33414 | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2023-10-04 | 1447 MEDICAL PARK BLVD, STE 405, WELLINGTON, FL 33414 | No data |
| CHANGE OF MAILING ADDRESS | 2023-10-04 | 1447 MEDICAL PARK BLVD, STE 405, WELLINGTON, FL 33414 | No data |
| REGISTERED AGENT NAME CHANGED | 2023-01-19 | BRANCIFORTE, LAUREN MARIE | No data |
| LC STMNT OF RA/RO CHG | 2018-12-13 | No data | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-02-06 |
| AMENDED ANNUAL REPORT | 2023-01-19 |
| ANNUAL REPORT | 2023-01-18 |
| ANNUAL REPORT | 2022-03-08 |
| ANNUAL REPORT | 2021-06-13 |
| ANNUAL REPORT | 2020-06-30 |
| ANNUAL REPORT | 2019-03-12 |
| CORLCRACHG | 2018-12-13 |
| Florida Limited Liability | 2018-02-02 |
Date of last update: 01 Feb 2025
Sources: Florida Department of State
