1336137280 NPI number — PHYSICIAN ASSOCIATES LLC

Table of content: (NPI 1336137280)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336137280 NPI number — PHYSICIAN ASSOCIATES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHYSICIAN ASSOCIATES LLC
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:
1336137280
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/04/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3090 CARUSO CT STE 50
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORLANDO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32806-8510
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-481-7139
Provider Business Mailing Address Fax Number:
407-481-7190

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
77 W UNDERWOOD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORLANDO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32806-1122
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-481-7139
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/13/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
STUBEE
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
AVP
Authorized Official Telephone Number:
407-481-7156

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 062757700 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 062757710 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".