1366554107 NPI number — DR. MARIE PRINSEN MD

Table of content: DR. MARIE PRINSEN MD (NPI 1366554107)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366554107 NPI number — DR. MARIE PRINSEN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PRINSEN
Provider First Name:
MARIE
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1366554107
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/11/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1000 36TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VERO BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32960-4862
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
772-567-4311
Provider Business Mailing Address Fax Number:
772-563-4723

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
801 WELLNESS WAY
Provider Second Line Business Practice Location Address:
SUITE 109
Provider Business Practice Location Address City Name:
SEBASTIAN
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32958-3783
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
772-581-5581
Provider Business Practice Location Address Fax Number:
772-563-4723
Provider Enumeration Date:
08/31/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  ME110076 , 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: 003853000 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 14F04 . This is a "BCBS OF FL" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".