1013160126 NPI number — FREDERICK EMERSON HASTY IV

Table of content: FREDERICK EMERSON HASTY IV (NPI 1013160126)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013160126 NPI number — FREDERICK EMERSON HASTY IV

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HASTY
Provider First Name:
FREDERICK
Provider Middle Name:
EMERSON
Provider Name Prefix Text:
Provider Name Suffix Text:
IV
Provider Credential Text:
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:
1013160126
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/11/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 816759
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOLLYWOOD
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33081-0759
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-964-2450
Provider Business Mailing Address Fax Number:
954-964-6084

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4300 ALTON RD
Provider Second Line Business Practice Location Address:
SUITE 1401
Provider Business Practice Location Address City Name:
MIAMI BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33140-2948
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-674-2742
Provider Business Practice Location Address Fax Number:
954-964-6084
Provider Enumeration Date:
11/03/2008

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: 207L00000X , with the licence number:  112976 , 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: 005548600 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 84926 . This is a "FLORIDA BLUE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 005548600 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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