1508005273 NPI number — ST. CLOUD NEUROLOGY, P.A.

Table of content: DR. IVAN RODRIGO ZENDEJAS RUIZ MD (NPI 1760542054)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508005273 NPI number — ST. CLOUD NEUROLOGY, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST. CLOUD NEUROLOGY, P.A.
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:
1508005273
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/29/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
451 SW BETHANY DR
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
PORT ST LUCIE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34986-1964
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
772-203-9356
Provider Business Mailing Address Fax Number:
772-249-0137

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
451 SW BETHANY DR
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
PORT ST LUCIE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34986-1964
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
772-203-9356
Provider Business Practice Location Address Fax Number:
772-249-0137
Provider Enumeration Date:
02/19/2009

Additional Information

Authorized Official

Authorized Official Last Name:
SCHMIDT
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICIAN/OWNER
Authorized Official Telephone Number:
772-204-5468

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X , with the licence number:  ME76267 , 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: 016053300 . 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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