1417190935 NPI number — MID-FLORIDA ENDOSCOPY & SURGERY CENTER LLC

Table of content: (NPI 1417190935)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417190935 NPI number — MID-FLORIDA ENDOSCOPY & SURGERY CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MID-FLORIDA ENDOSCOPY & SURGERY CENTER 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:
1417190935
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/17/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1950 SW 18TH CT
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
OCALA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34471-7857
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-861-8555
Provider Business Mailing Address Fax Number:
352-401-0124

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1950 SW 18TH CT
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
OCALA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34471-7857
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-861-8555
Provider Business Practice Location Address Fax Number:
352-401-0124
Provider Enumeration Date:
04/14/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KUMAR
Authorized Official First Name:
THIMMIAH
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
352-861-8555

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  1327 , 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: 002837600 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".