1932285178 NPI number — MS. EDA SUSAN RENIERI MASTECTOMY FITTER

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 1932285178 NPI number — MS. EDA SUSAN RENIERI MASTECTOMY FITTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RENIERI
Provider First Name:
EDA
Provider Middle Name:
SUSAN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MASTECTOMY FITTER
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PEITHMAN
Provider Other First Name:
EDA
Provider Other Middle Name:
SUSAN
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
(MASTECTOMY FITTER)
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1932285178
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/24/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
517 EAST STRAWBRIDGE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MELBOURNE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32901
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-728-9442
Provider Business Mailing Address Fax Number:
321-728-9440

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
517 EAST STRAWBRIDGE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MELBOURNE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32901
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-728-9442
Provider Business Practice Location Address Fax Number:
321-728-9440
Provider Enumeration Date:
10/31/2006

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: 225000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 224900000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: M2733 . This is a "BLUE CROSS BLUE SHIELD FL" identifier . This identifiers is of the category "OTHER".
  • Identifier: 44539000 . This is a "CIGNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".