1467628156 NPI number — THORACIC SURGERY OF INDIAN RIVER LLC

Table of content: (NPI 1467628156)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467628156 NPI number — THORACIC SURGERY OF INDIAN RIVER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THORACIC SURGERY OF INDIAN RIVER 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:
1467628156
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/21/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14430 US HIGHWAY 1
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
SEBASTIAN
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32958-3289
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
772-589-2009
Provider Business Mailing Address Fax Number:
772-589-2299

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14430 US HIGHWAY 1
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
SEBASTIAN
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32958-3289
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
772-589-2009
Provider Business Practice Location Address Fax Number:
772-589-2299
Provider Enumeration Date:
05/02/2008

Additional Information

Authorized Official

Authorized Official Last Name:
SEIRAFI
Authorized Official First Name:
PETER
Authorized Official Middle Name:
A
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
772-589-2009

Provider Taxonomy Codes

  • Taxonomy code: 208G00000X , with the licence number:  ME80733 , 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: 2610659 . This is a "CIGNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 35676 . This is a "BCBS FLORIDA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 613325100 . This is a "FEDERAL BLACK LUNG" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7435144 . This is a "AETNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: DN6310 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 162138 . This is a "WELLCARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: PRO6612 . This is a "QUALITY HEALTH PLAN" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 1865828 . This is a "AETNA FL" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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