1063572295 NPI number — OPTUMCARE FLORIDA, LLC

Table of content: (NPI 1063572295)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063572295 NPI number — OPTUMCARE FLORIDA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OPTUMCARE FLORIDA, 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:
JSA HEALTHCARE CORPORATION
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:
1063572295
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/19/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10051 5TH STREET NORTH
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST. PETERSBURG
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33702-2299
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-849-9373
Provider Business Mailing Address Fax Number:
727-841-0497

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4757 US HIGHWAY 19
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW PORT RICHEY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34652-4945
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-849-9373
Provider Business Practice Location Address Fax Number:
727-841-0497
Provider Enumeration Date:
12/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LIETHEN
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
G.
Authorized Official Title or Position:
SECRETARY
Authorized Official Telephone Number:
952-205-6262

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  PH18603 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336M0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 030843900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4399230001 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2014572 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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