1508975186 NPI number — DR. RICHARD DOMINICK SERIANNI DPT

Table of content: DR. RICHARD DOMINICK SERIANNI DPT (NPI 1508975186)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508975186 NPI number — DR. RICHARD DOMINICK SERIANNI DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SERIANNI
Provider First Name:
RICHARD
Provider Middle Name:
DOMINICK
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
M

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:
1508975186
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/24/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2800 E COMMERCIAL BLVD
Provider Second Line Business Mailing Address:
SUITE #207
Provider Business Mailing Address City Name:
FT LAUDERDALE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33308-4229
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-491-2021
Provider Business Mailing Address Fax Number:
954-622-9791

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2800 E COMMERCIAL BLVD
Provider Second Line Business Practice Location Address:
SUITE #207
Provider Business Practice Location Address City Name:
FT LAUDERDALE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33308-4229
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-491-2021
Provider Business Practice Location Address Fax Number:
954-622-9791
Provider Enumeration Date:
08/29/2006

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: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: PT21205 . This is a "LICENSE #" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 112719600 . 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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