1508859547 NPI number — K. LESLIE AVERY M.D.

Table of content: K. LESLIE AVERY M.D. (NPI 1508859547)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508859547 NPI number — K. LESLIE AVERY M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
AVERY
Provider First Name:
K.
Provider Middle Name:
LESLIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1508859547
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
DEPT OF PEDIATRIC CRITICAL CARE SHANDS
Provider Second Line Business Mailing Address:
1600 SW ARCHER RD, STE. 10-504, BOX 100296
Provider Business Mailing Address City Name:
GAINESVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32610-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-265-0462
Provider Business Mailing Address Fax Number:
352-265-0443

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
DEPT OF PEDIATRIC CRITICAL CARE SHANDS
Provider Second Line Business Practice Location Address:
1600 SW ARCHER RD, STE. 10-504, BOX 100296
Provider Business Practice Location Address City Name:
GAINESVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32610-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-265-0462
Provider Business Practice Location Address Fax Number:
352-265-0443
Provider Enumeration Date:
08/24/2005

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: 2080P0203X , with the licence number:  ME115725 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2080P0203X , with the licence number: 11316 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2080P0203X , with the licence number: A67929 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2080P0203X , with the licence number: DR.0071896 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 008799300 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".