1588742977 NPI number — LIGHTHOUSE INTERNAL MEDICINE AND PRIMARY CARE PA

Table of content: (NPI 1588742977)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588742977 NPI number — LIGHTHOUSE INTERNAL MEDICINE AND PRIMARY CARE PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIGHTHOUSE INTERNAL MEDICINE 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:
1588742977
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/21/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5757 BOOTH RD BLDG 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32207-5981
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-636-9510
Provider Business Mailing Address Fax Number:
904-636-9512

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5757 BOOTH RD.
Provider Second Line Business Practice Location Address:
#200
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32207
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-636-9510
Provider Business Practice Location Address Fax Number:
904-636-9512
Provider Enumeration Date:
11/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
XIE
Authorized Official First Name:
CHONGLUN
Authorized Official Middle Name:
Authorized Official Title or Position:
MD
Authorized Official Telephone Number:
904-636-9510

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  ME92689 , 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: 009831900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 40311 . This is a "BCBS FL" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 273938100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 009831900 . 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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