1518980937 NPI number — DOCTORS INLET PEDIATRICS AND PRIMARY CARE, PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518980937 NPI number — DOCTORS INLET PEDIATRICS AND PRIMARY CARE, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DOCTORS INLET PEDIATRICS AND PRIMARY CARE, PA
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:
1518980937
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
430 COLLEGE DR
Provider Second Line Business Mailing Address:
SUITE 100-102-104-106
Provider Business Mailing Address City Name:
MIDDLEBURG
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32068-8531
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-298-1994
Provider Business Mailing Address Fax Number:
904-298-1973

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
430 COLLEGE DR STE 100-102-104-106
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIDDLEBURG
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32068
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-298-1994
Provider Business Practice Location Address Fax Number:
904-298-1973
Provider Enumeration Date:
07/26/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
TILAK
Authorized Official First Name:
MILIND
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
904-298-1994

Provider Taxonomy Codes

  • Taxonomy code: 207QA0505X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208VP0014X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 94792 . This is a "BC/BS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 2941225 . This is a "AETNA GROUP ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: K6020 . This is a "MEDICARE GROUP" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".