| Entity Name: | INSTITUTE OF INTERNAL MEDICINE, P.A. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Inactive |
| Date Filed: | 09 Aug 1999 (26 years ago) |
| Date of dissolution: | 27 Sep 2019 (5 years ago) |
| Last Event: | ADMIN DISSOLUTION FOR ANNUAL REPORT |
| Event Date Filed: | 27 Sep 2019 (5 years ago) |
| Document Number: | P99000072610 |
| FEI/EIN Number | 593638351 |
| Address: | 1301 PLANTATION ISLAND DRIVE, SUITE402B, SAINT AUGUSTINE, FL, 32080 |
| Mail Address: | 1301 PLANTATION ISLAND DRIVE, SUITE402B, SAINT AUGUSTINE, FL, 32080 |
| ZIP code: | 32080 |
| County: | St. Johns |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1457523003 | 2008-03-24 | 2011-09-15 | 1301 PLANTATION ISLAND DR S, STE 402-B, ST AUGUSTINE, FL, 320803108, US | 1301 PLANTATION ISLAND DR S, STE 402B, ST AUGUSTINE, FL, 320803108, US | |||||||||||||||||||||||||||||||||||||||||||
|
|||||||||||||||||||||||||||||||||||||||||||||||
| Phone | +1 904-460-0707 |
Authorized person
| Name | CARMEN C VIVERO |
| Role | PRESIDENT |
| Phone | 9044600707 |
Taxonomy
| Taxonomy Code | 207R00000X - Internal Medicine Physician |
| License Number | ME76599 |
| State | FL |
| Is Primary | Yes |
| Taxonomy Code | 207RA0401X - Addiction Medicine (Internal Medicine) Physician |
| License Number | ME76599 |
| State | FL |
| Is Primary | No |
Other Provider Identifiers
| Issuer | RR MEDICARE |
| Number | DN9360 |
| State | FL |
| Issuer | BCBS |
| Number | 44784 |
| State | FL |
| Issuer | MEDICAID |
| Number | 003271700 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| VIVERO CARMEN | Agent | 1301 PLANTATION ISLAND DRIVE, SAINT AUGUSTINE, FL, 32084 |
| Name | Role | Address |
|---|---|---|
| VIVERO CARMEN | President | 1301 PLANTATION ISLAND DRIVE, SAINT AUGUSTINE, FL, 32080 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2019-09-27 | No data | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2012-04-11 | 1301 PLANTATION ISLAND DRIVE, SUITE402B, SAINT AUGUSTINE, FL 32080 | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2012-04-11 | 1301 PLANTATION ISLAND DRIVE, SAINT AUGUSTINE, FL 32084 | No data |
| REINSTATEMENT | 2012-04-11 | No data | No data |
| CHANGE OF MAILING ADDRESS | 2012-04-11 | 1301 PLANTATION ISLAND DRIVE, SUITE402B, SAINT AUGUSTINE, FL 32080 | No data |
| REGISTERED AGENT NAME CHANGED | 2012-04-11 | VIVERO, CARMEN | No data |
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2006-09-15 | No data | No data |
| Document Number | Status | Case Number | Name of Court | Date of Entry | Expiration Date | Amount Due | Plaintiff |
|---|---|---|---|---|---|---|---|
| J22000266082 | ACTIVE | 1000000924513 | ST JOHNS | 2022-05-26 | 2032-06-01 | $ 881.38 | STATE OF FLORIDA, DEPARTMENT OF REVENUE, JACKSONVILLE SERVICE CENTER, 921 N DAVIS ST STE 250A, JACKSONVILLE FL322096825 |
| J21000264006 | ACTIVE | 1000000890323 | ST JOHNS | 2021-05-24 | 2031-05-26 | $ 1,192.31 | STATE OF FLORIDA, DEPARTMENT OF REVENUE, JACKSONVILLE SERVICE CENTER, 921 N DAVIS ST STE 250A, JACKSONVILLE FL322096825 |
| J19000733723 | ACTIVE | 1000000846814 | ST JOHNS | 2019-10-30 | 2029-11-06 | $ 707.29 | STATE OF FLORIDA, DEPARTMENT OF REVENUE, JACKSONVILLE SERVICE CENTER, 921 N DAVIS ST STE 250A, JACKSONVILLE FL322096825 |
| J19000192961 | ACTIVE | 1000000818384 | ST JOHNS | 2019-03-05 | 2029-03-13 | $ 413.03 | STATE OF FLORIDA, DEPARTMENT OF REVENUE, JACKSONVILLE SERVICE CENTER, 921 N DAVIS ST STE 250A, JACKSONVILLE FL322096825 |
| J18000150490 | TERMINATED | 1000000778976 | ST JOHNS | 2018-04-09 | 2028-04-11 | $ 645.15 | STATE OF FLORIDA, DEPARTMENT OF REVENUE, JACKSONVILLE SERVICE CENTER, 921 N DAVIS ST STE 250A, JACKSONVILLE FL322096825 |
| J17000582611 | TERMINATED | 1000000758562 | ST JOHNS | 2017-10-09 | 2027-10-20 | $ 1,020.74 | STATE OF FLORIDA, DEPARTMENT OF REVENUE, JACKSONVILLE SERVICE CENTER, 921 N DAVIS ST STE 250A, JACKSONVILLE FL322096825 |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2018-04-07 |
| ANNUAL REPORT | 2017-04-26 |
| ANNUAL REPORT | 2016-04-25 |
| ANNUAL REPORT | 2015-03-18 |
| ANNUAL REPORT | 2014-03-28 |
| ANNUAL REPORT | 2013-04-25 |
| REINSTATEMENT | 2012-04-11 |
| ANNUAL REPORT | 2005-04-22 |
| ANNUAL REPORT | 2004-04-30 |
| ANNUAL REPORT | 2003-01-23 |
Date of last update: 01 Feb 2025
Sources: Florida Department of State
