1871535955 NPI number — PENSACOLA NEPHROLOGY 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 1871535955 NPI number — PENSACOLA NEPHROLOGY PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PENSACOLA NEPHROLOGY 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:
RENALUS CENTER FOR KIDNEY CARE
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:
1871535955
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/11/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 11037
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PENSACOLA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32524-1037
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-444-4700
Provider Business Mailing Address Fax Number:
850-444-7497

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
319 GREEN ACRES RD STE 103
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT WALTON BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32547-1170
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-862-2385
Provider Business Practice Location Address Fax Number:
850-862-0482
Provider Enumeration Date:
06/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ROS
Authorized Official First Name:
SHANTELLE
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALS COORDINATOR
Authorized Official Telephone Number:
850-444-7000

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RN0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 256870500 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 256870503 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 256870506 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 529904030 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: CF9776 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 256870502 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 256870507 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 256870508 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 256870505 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0358 . This is a "MED3000/HEALTH 1ST NETWOR" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 99659 . This is a "BCBS OF FLORIDA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 256870501 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 256870504 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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