| Entity Name: | FAMILY PRACTICE-ST. CLOUD, INC. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Active |
| Date Filed: | 23 Oct 1989 (35 years ago) |
| Document Number: | L25100 |
| FEI/EIN Number | 592974863 |
| Address: | 601 S. HARBOUR ISLAND BLVD., TAMPA, FL, 33602, US |
| Mail Address: | 601 S. HARBOUR ISLAND BLVD., TAMPA, FL, 33602, US |
| ZIP code: | 33602 |
| County: | Hillsborough |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1336189190 | 2006-06-08 | 2023-02-06 | 3100 17TH ST, SAINT CLOUD, FL, 347696021, US | 3100 17TH ST, SAINT CLOUD, FL, 347696021, US | |||||||||||||||||||||||||
|
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| Phone | +1 407-892-0009 |
| Fax | 4078923285 |
Authorized person
| Name | DR. JOHN FREDERICK WILKER |
| Role | PRESIDENT |
| Phone | 4078920009 |
Taxonomy
| Taxonomy Code | 207Q00000X - Family Medicine Physician |
| License Number | ME0036943 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | BLUE CROSS BLUE SHEILD |
| Number | 34984 |
| State | FL |
| Name | Role |
|---|---|
| C T CORPORATION SYSTEM | Agent |
| Name | Role | Address |
|---|---|---|
| Polen Michael | Chief Executive Officer | 601 S. HARBOUR ISLAND BLVD., TAMPA, FL, 33602 |
| Name | Role | Address |
|---|---|---|
| Kollefrath Daniel | President | 601 S. HARBOUR ISLAND BLVD., TAMPA, FL, 33602 |
| Name | Role | Address |
|---|---|---|
| Pagidipati Rudrama | Vice President | 601 S. HARBOUR ISLAND BLVD., TAMPA, FL, 33602 |
| Name | Role | Address |
|---|---|---|
| Haber Michael | Secretary | 601 S. HARBOUR ISLAND BLVD., TAMPA, FL, 33602 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G21000156649 | PROHEALTH FAMILY PHYSICIANS | ACTIVE | 2021-11-24 | 2026-12-31 | No data | 601 S HARBOUR ISLAND BLVD, SUITE 213-A, TAMPA, FL, 33602 |
| G15000071073 | PROHEALTH KISSIMMEE | EXPIRED | 2015-07-08 | 2020-12-31 | No data | 3100 17TH STREET, SAINT CLOUD, FL, 34769 |
| G13000020815 | PROHEALTH HARMONY | EXPIRED | 2013-02-28 | 2018-12-31 | No data | 7264 HARMONY SQUARE DR. SOUTH, HARMONY, FL, 34773 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| AMENDMENT AND NAME CHANGE | 2021-11-24 | FAMILY PRACTICE-ST. CLOUD, INC. | No data |
| AMENDMENT | 2016-11-14 | No data | No data |
| AMENDMENT | 2004-02-11 | No data | No data |
| REINSTATEMENT | 1998-04-09 | No data | No data |
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 1997-09-26 | No data | No data |
Date of last update: 01 Feb 2025
Sources: Florida Department of State
