1750497350 NPI number — MARK KONWISER MD PA

Table of content: (NPI 1447428594)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750497350 NPI number — MARK KONWISER MD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARK KONWISER MD 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:
MARK KONWISER MD PA
Provider Other Organization Name Type Code:
3
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:
1750497350
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/21/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
900 PINE ST
Provider Second Line Business Mailing Address:
BLDG 1 STE 122
Provider Business Mailing Address City Name:
ENGLEWOOD
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34223-4418
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
941-474-8811
Provider Business Mailing Address Fax Number:
941-473-0058

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
900 PINE ST
Provider Second Line Business Practice Location Address:
BLDG 1 STE 122
Provider Business Practice Location Address City Name:
ENGLEWOOD
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34223-4418
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-474-8811
Provider Business Practice Location Address Fax Number:
941-473-0058
Provider Enumeration Date:
08/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KONWISER
Authorized Official First Name:
MARK
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/PHYSICIAN
Authorized Official Telephone Number:
941-474-8811

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  ME00050766 , 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: 85944 . This is a "OCCUPATIONAL LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: ME00050766 . This is a "LIC NUMBER FLORIDA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 22-0003555 . This is a "RAIL ROAD MEDICARE #" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 10D0295356 . This is a "CLIA #" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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