1164754602 NPI number — T R SUGGS MD MEDICAL CLINIC PA

Table of content: (NPI 1164754602)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164754602 NPI number — T R SUGGS MD MEDICAL CLINIC PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
T R SUGGS MD MEDICAL CLINIC PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164754602
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/12/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 98
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CRESCENT CITY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32112-0098
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-698-1221
Provider Business Mailing Address Fax Number:
386-698-1514

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 S MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CRESCENT CITY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32112-2729
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-698-1221
Provider Business Practice Location Address Fax Number:
386-698-1514
Provider Enumeration Date:
02/09/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SUGGS
Authorized Official First Name:
THELBERT
Authorized Official Middle Name:
R
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
386-698-1221

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 045328500 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 012686688 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".