1063754729 NPI number — DR. KYLE G LUECKE M.D.

Table of content: DR. KYLE G LUECKE M.D. (NPI 1063754729)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063754729 NPI number — DR. KYLE G LUECKE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LUECKE
Provider First Name:
KYLE
Provider Middle Name:
G
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1063754729
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/03/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 919379
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:
32891-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
844-453-1406
Provider Business Mailing Address Fax Number:
772-621-3180

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1200 7TH AVE N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST PETERSBURG
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33705-1300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-825-1100
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/20/2013

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: 2085R0202X , with the licence number:  0101264153 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: ME140753 , 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: LN182 . This is a "FL MEDICARE PTAN" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: OBE1C . This is a "FL BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 103610100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: P02293237 . This is a "FL RAILROAD MEDICARE PTAN" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 1063754729 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 103610100 . 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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