1487803698 NPI number — CALLENBERGER ORTHOPEDIC SPECIALISTS LLC

Table of content: CYNTHIA JEANNE CORNELIUS D.P.M. (NPI 1235287079)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487803698 NPI number — CALLENBERGER ORTHOPEDIC SPECIALISTS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CALLENBERGER ORTHOPEDIC SPECIALISTS 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:
1487803698
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/01/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
205 N BANANA RIVER DR
Provider Second Line Business Mailing Address:
SUITE 103
Provider Business Mailing Address City Name:
MERRITT ISLAND
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32952-2596
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-305-4931
Provider Business Mailing Address Fax Number:
321-305-4933

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
205 N BANANA RIVER DR
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
MERRITT ISLAND
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32952-2596
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-305-4931
Provider Business Practice Location Address Fax Number:
321-305-4933
Provider Enumeration Date:
09/11/2008

Additional Information

Authorized Official

Authorized Official Last Name:
CALLENBERGER
Authorized Official First Name:
MARK
Authorized Official Middle Name:
STEVEN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
321-305-4931

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  8441 , 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: 009720700 . 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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