1952389538 NPI number — DR. MARK BRODEUR MD

Table of content: DR. MARK BRODEUR MD (NPI 1952389538)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952389538 NPI number — DR. MARK BRODEUR MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRODEUR
Provider First Name:
MARK
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1952389538
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/30/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 860554
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORLANDO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32886-0554
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-346-3606
Provider Business Mailing Address Fax Number:
904-346-0113

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3625 UNIVERSITY BLVD S
Provider Second Line Business Practice Location Address:
EMERGENCY DEPT
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32216-4207
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-346-3606
Provider Business Practice Location Address Fax Number:
904-346-0113
Provider Enumeration Date:
01/04/2006

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: 207PE0004X , with the licence number:  ME0090285 , 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: 44098 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 269864100 . This is a "FLORIDA MEDICAID" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: P00139639 . This is a "RRMCR" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 269864100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00139639 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 787365756A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 269864100 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com