| Entity Name: | EDWARD FETHEROLF, M.D., P.A. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Inactive |
| Date Filed: | 31 Dec 2003 (21 years ago) |
| Date of dissolution: | 26 Sep 2014 (10 years ago) |
| Last Event: | ADMIN DISSOLUTION FOR ANNUAL REPORT |
| Event Date Filed: | 26 Sep 2014 (10 years ago) |
| Document Number: | P04000000963 |
| FEI/EIN Number | 200545408 |
| Address: | 1500 PLACIDA RD, SUITE B2, ENGLEWOOD, FL, 34223 |
| Mail Address: | 1273 SOUTHBAY DR, OSPREY, FL, 34229 |
| ZIP code: | 34223 |
| County: | Sarasota |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1730378282 | 2007-10-22 | 2015-05-13 | 1500 PLACIDA RD, SUITE B2, ENGLEWOOD, FL, 342234955, US | 1500 PLACIDA RD, SUITE B2, ENGLEWOOD, FL, 342234955, US | |||||||||||||||||||||||||
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| Phone | +1 941-474-2266 |
| Fax | 9414757274 |
Authorized person
| Name | DR. EDWARD C FETHEROLF |
| Role | PRESIDENT |
| Phone | 9414742266 |
Taxonomy
| Taxonomy Code | 207W00000X - Ophthalmology Physician |
| License Number | ME30596 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 374759000 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| PRIDEMORE & ASSOCIATES, CPAS, PA | Agent | 229 TAMIAMI TRAIL S, VENICE, FL, 34285 |
| Name | Role | Address |
|---|---|---|
| FETHEROLF EDWARD | Director | 1273 SOUTHBAY DR, OSPREY, FL, 34229 |
| Name | Role | Address |
|---|---|---|
| FETHEROLF EDWARD | President | 1273 SOUTHBAY DR, OSPREY, FL, 34229 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2014-09-26 | No data | No data |
| CANCEL ADM DISS/REV | 2006-09-27 | No data | No data |
| REGISTERED AGENT NAME CHANGED | 2006-09-27 | PRIDEMORE & ASSOCIATES, CPAS, PA | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2006-09-27 | 229 TAMIAMI TRAIL S, VENICE, FL 34285 | No data |
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2006-09-15 | No data | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2004-04-22 | 1500 PLACIDA RD, SUITE B2, ENGLEWOOD, FL 34223 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2013-03-31 |
| ANNUAL REPORT | 2012-03-29 |
| ANNUAL REPORT | 2011-04-28 |
| ANNUAL REPORT | 2010-04-29 |
| ANNUAL REPORT | 2009-04-29 |
| ANNUAL REPORT | 2008-02-11 |
| ANNUAL REPORT | 2007-07-16 |
| REINSTATEMENT | 2006-09-27 |
| ANNUAL REPORT | 2005-08-10 |
| ANNUAL REPORT | 2004-04-22 |
Date of last update: 01 Feb 2025
Sources: Florida Department of State
