| Entity Name: | DIAGNOSTIC CLINIC MEDICAL GROUP, INC. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Active |
| Date Filed: | 24 Mar 1995 (30 years ago) |
| Document Number: | P95000023879 |
| FEI/EIN Number | 593307922 |
| Address: | 1301 2ND AVENUE SW, LARGO, FL, 33770, US |
| Mail Address: | 1301 2ND AVENUE SW, LARGO, FL, 33770, US |
| ZIP code: | 33770 |
| County: | Pinellas |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1538833454 | 2021-08-04 | 2021-08-04 | 385 CYPRESS GARDENS BLVD, WINTER HAVEN, FL, 338804452, US | 385 CYPRESS GARDENS BLVD, WINTER HAVEN, FL, 338804452, US | |||||||||||||||||||||||||
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| Phone | +1 863-356-3754 |
| Fax | 8633565200 |
Authorized person
| Name | GINA MARIE PREBECK |
| Role | VP OF OPERATIONS |
| Phone | 7275599461 |
Taxonomy
| Taxonomy Code | 207R00000X - Internal Medicine Physician |
| Is Primary | Yes |
| Taxonomy Code | 363LF0000X - Family Nurse Practitioner |
| Is Primary | No |
Other Provider Identifiers
| Issuer | FLORIDA BLUE |
| Number | 00036 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| MACCARTHY DEIRDRE | Agent | 4800 DEERWOOD CAMPUS PARKWAY 100-7, JACKSONVILLE, FL, 32246 |
| Name | Role | Address |
|---|---|---|
| Schrader Elana Dr. | Chairman | 4800 DEERWOOD CAMPUS PARKWAY DC 1-8, JACKSONVILLE, FL, 32246 |
| Name | Role | Address |
|---|---|---|
| Hall Allen Esq. | Secretary | 4800 DEERWOOD CAMPUS PARKWAY DC 1-7, JACKSONVILLE, FL, 32246 |
| Name | Role | Address |
|---|---|---|
| Trotter-Mitchell Shawn | Director | 4800 DEERWOOD CAMPUS PARKWAY DC 1-8, JACKSONVILLE, FL, 32246 |
| Name | Role | Address |
|---|---|---|
| WILLIAMS TRACY Dr. | President | 4800 DEERWOOD CAMPUS PARKWAY DC 1-9, JACKSONVILLE, FL, 32246 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G21000105249 | GUIDEWELL PRIMARY CARE | ACTIVE | 2021-08-16 | 2026-12-31 | No data | 4800 DEERWOOD CAMPUS PARKWAY, JACKSONVILLE, FL, 32246 |
| G21000105248 | GUIDEWELL PRIMARY CARE | ACTIVE | 2021-08-16 | 2026-12-31 | No data | 385 CYPRESS GARDENS BLVD, WINTER HAVEN, FL, 33880 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| AMENDED AND RESTATEDARTICLES/NAME CHANGE | 2012-12-28 | DIAGNOSTIC CLINIC MEDICAL GROUP, INC. | No data |
| AMENDMENT | 2000-02-25 | No data | No data |
| RESTATED ARTICLES | 1995-04-26 | No data | No data |
Date of last update: 03 Jan 2025
Sources: Florida Department of State
