| Entity Name: | PHOENIX INTERNAL MEDICINE LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Company |
| Status: | Active |
| Date Filed: | 04 Feb 2019 (6 years ago) |
| Document Number: | L19000034571 |
| FEI/EIN Number | 83-3625533 |
| Address: | 436 Selkirk Drive, WINTER PARK, FL 32792 |
| Mail Address: | 127 W FAIRBANKS AVENUE #374, WINTER PARK, FL 32789 |
| ZIP code: | 32792 |
| County: | Orange |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1558823500 | 2019-04-01 | 2020-10-09 | 127 W FAIRBANKS AVE # 374, WINTER PARK, FL, 327894326, US | 5579 S ORANGE AVE, EDGEWOOD, FL, 328093493, US | |||||||||||||||||||||
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| Phone | +1 407-906-5092 |
| Fax | 4076418133 |
Authorized person
| Name | ROBERT POWERS |
| Role | PRESIDENT |
| Phone | 4079065092 |
Taxonomy
| Taxonomy Code | 208M00000X - Hospitalist Physician |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 003812400 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| POWERS, ROBERT B | Agent | 127 W FAIRBANKS AVENUE #374, WINTER PARK, FL 32789 |
| Name | Role | Address |
|---|---|---|
| POWERS, ROBERT | Authorized Member | 127 W FAIRBANKS AVENUE #374, WINTER PARK, FL 32789 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF PRINCIPAL ADDRESS | 2023-08-11 | 436 Selkirk Drive, WINTER PARK, FL 32792 | No data |
| CHANGE OF MAILING ADDRESS | 2020-02-25 | 436 Selkirk Drive, WINTER PARK, FL 32792 | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2020-02-25 | 127 W FAIRBANKS AVENUE #374, WINTER PARK, FL 32789 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-03-25 |
| AMENDED ANNUAL REPORT | 2023-08-11 |
| ANNUAL REPORT | 2023-02-27 |
| ANNUAL REPORT | 2022-08-24 |
| ANNUAL REPORT | 2021-05-28 |
| ANNUAL REPORT | 2020-02-25 |
| Florida Limited Liability | 2019-02-04 |
Date of last update: 17 Jan 2025
Sources: Florida Department of State
