1356448534 NPI number — THE VASCULAR CLINIC & COSMETIC VEIN TREATMENT CENTER PL

Table of content: (NPI 1356448534)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356448534 NPI number — THE VASCULAR CLINIC & COSMETIC VEIN TREATMENT CENTER PL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE VASCULAR CLINIC & COSMETIC VEIN TREATMENT CENTER PL
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:
SCOTT R HANNUM DO PL
Provider Other Organization Name Type Code:
3
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:
1356448534
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/01/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 620696
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:
32862-0696
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-518-4982
Provider Business Mailing Address Fax Number:
407-518-1748

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
720 W OAK ST STE 309
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KISSIMMEE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34741-4910
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-518-4982
Provider Business Practice Location Address Fax Number:
407-518-1748
Provider Enumeration Date:
09/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HANNUM
Authorized Official First Name:
SCOTT
Authorized Official Middle Name:
R
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
407-518-4982

Provider Taxonomy Codes

  • Taxonomy code: 2086S0129X , with the licence number:  OS8740 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 17027 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 264703600 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 112891700 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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