1982922829 NPI number — INTERNAL MEDICINE AND PEDIATRICS ASSOCIATESOF TALLAHASSEE INC

Table of content: (NPI 1982922829)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982922829 NPI number — INTERNAL MEDICINE AND PEDIATRICS ASSOCIATESOF TALLAHASSEE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTERNAL MEDICINE AND PEDIATRICS ASSOCIATESOF TALLAHASSEE INC
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:
IMPACT BEHAVIORAL HEALTH LLC
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:
1982922829
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/01/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1965 CAPITAL CIR NE STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TALLAHASSEE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32308-8402
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-656-2006
Provider Business Mailing Address Fax Number:
850-656-2820

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1965 CAPITAL CIR NE
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
TALLAHASSEE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32308-8401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-671-4600
Provider Business Practice Location Address Fax Number:
850-878-2863
Provider Enumeration Date:
05/16/2010

Additional Information

Authorized Official

Authorized Official Last Name:
MIGNON
Authorized Official First Name:
YVETTE
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
850-656-2006

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X , with the licence number:  8447 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X , with the licence number: 8447 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 104100000X , with the licence number: 6702 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 6702 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 324500000X , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 324500000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 600680931 . This is a "MAGELLAN" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 2386 . This is a "LICENSED PROFESSIONAL COUNSELOR" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 648299630A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003214900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8447 . This is a "LICENSED MENTAL HEALTH COUNSELOR" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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