| Entity Name: | PETER G. WERNICKI, M.D., P.A. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Active |
| Date Filed: | 22 Jul 1999 (26 years ago) |
| Document Number: | P99000064996 |
| FEI/EIN Number | 650938033 |
| Address: | 787 37TH Street,, VERO BEACH, FL, 32960, US |
| Mail Address: | 787 37TH Street,, VERO BEACH, FL, 32960, US |
| ZIP code: | 32960 |
| County: | Indian River |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1063441731 | 2006-07-03 | 2022-08-10 | 787 37TH ST STE E200, VERO BEACH, FL, 329607306, US | 787 37TH ST STE E200, VERO BEACH, FL, 329607306, US | |||||||||||||||||||||||||||
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| Phone | +1 772-978-7808 |
| Fax | 7729789320 |
Authorized person
| Name | MRS. AMANDA P MULLIKIN |
| Role | ADMIN ASSISTANT |
| Phone | 7729787808 |
Taxonomy
| Taxonomy Code | 207X00000X - Orthopaedic Surgery Physician |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 266151900 |
| State | FL |
| Issuer | BLUE CROSS BLUE SHIELD FL |
| Number | 45408 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| WILLIAMS ANDREW | Agent | 1575 INDIAN RIVER BLVD, VERO BEACH, FL, 32960 |
| Name | Role | Address |
|---|---|---|
| WERNICKI PETER G | Director | 11840 SEAVIEW DRIVE, VERO BEACH, FL, 32963 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G14000038465 | PRO SPORTS | EXPIRED | 2014-04-17 | 2024-12-31 | No data | 1355 37TH STREET, SUITE 301, VERO BEACH, FL, 32960 |
| G99257900093 | PRO SPORTS PROFESSIONAL SPORTS MEDICINE & ORTHOPAEDIC SURGERY | EXPIRED | 1999-09-14 | 2024-12-31 | No data | 1355 37TH STREET, STE 301, VERO BEACH, FL, 32960 |
Date of last update: 02 Jan 2025
Sources: Florida Department of State
