1013300912 NPI number — PHYSICIANS HOUSECALL TEAM, LLC

Table of content: (NPI 1013300912)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013300912 NPI number — PHYSICIANS HOUSECALL TEAM, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHYSICIANS HOUSECALL TEAM, LLC
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:
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:
1013300912
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/16/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3616 HARDEN BLVD
Provider Second Line Business Mailing Address:
#311
Provider Business Mailing Address City Name:
LAKELAND
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33803-5938
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
863-268-2921
Provider Business Mailing Address Fax Number:
863-268-2923

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1225 HAVENDALE BLVD NW
Provider Second Line Business Practice Location Address:
#338
Provider Business Practice Location Address City Name:
WINTER HAVEN
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33881-1349
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-268-2921
Provider Business Practice Location Address Fax Number:
863-268-2923
Provider Enumeration Date:
03/17/2015

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
DEAN
Authorized Official First Name:
BYRON
Authorized Official Middle Name:
RENARD
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
407-719-6673

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  OS9203 , 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: 245345600 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".