| Entity Name: | PHYSICIAN SERVICES IPA, LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Foreign Limited Liability Co. |
| Status: | Active |
| Date Filed: | 20 Dec 2018 (6 years ago) |
| Branch of: | PHYSICIAN SERVICES IPA, LLC, NEW YORK (Company Number 4437735) |
| Last Event: | REINSTATEMENT |
| Event Date Filed: | 15 Nov 2023 (a year ago) |
| Document Number: | M18000011517 |
| FEI/EIN Number | 463503852 |
| Address: | 3113 LAWTON RD., STE 250, ORLANDO, FL, 32803, US |
| Mail Address: | 3113 LAWTON RD., STE 250, ORLANDO, FL, 32803, US |
| ZIP code: | 32803 |
| County: | Orange |
| Place of Formation: | NEW YORK |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1336573351 | 2013-08-27 | 2013-08-27 | 400 GATLIN AVE, ORLANDO, FL, 328066940, US | 400 GATLIN AVE, ORLANDO, FL, 328066940, US | |||||||||||||||||||
|
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| Phone | +1 888-829-8550 |
| Fax | 8888437191 |
Authorized person
| Name | MR. CASEY B DELOACH |
| Role | MANAGER |
| Phone | 8888298550 |
Taxonomy
| Taxonomy Code | 207Q00000X - Family Medicine Physician |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICARE PTAN |
| Number | PHC059 |
| Name | Role |
|---|---|
| CORPORATION SERVICE COMPANY | Agent |
| Name | Role | Address |
|---|---|---|
| McGinn James | Auth | 3113 LAWTON RD., STE 250, ORLANDO, FL, 32803 |
| Name | Role |
|---|---|
| VAXCARE, LLC | Manager |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| REINSTATEMENT | 2023-11-15 | No data | No data |
| REGISTERED AGENT NAME CHANGED | 2023-11-15 | Corporation Service Company | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2023-11-15 | 1201 Hays Street, TALLAHASSEE, FL 32301 | No data |
| REVOKED FOR ANNUAL REPORT | 2022-09-23 | No data | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-04-15 |
| REINSTATEMENT | 2023-11-15 |
| ANNUAL REPORT | 2021-02-10 |
| ANNUAL REPORT | 2020-04-28 |
| ANNUAL REPORT | 2019-06-26 |
| Foreign Limited | 2018-12-20 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
