1093710790 NPI number — DR. JOHN RICHARD HURT II M.D.

Table of content: DEVONTE THOMAS (NPI 1346949310)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093710790 NPI number — DR. JOHN RICHARD HURT II M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HURT
Provider First Name:
JOHN
Provider Middle Name:
RICHARD
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
II
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:
1093710790
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/17/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
511 MEDICAL PLAZA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEESBURG
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34748-7326
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-728-6808
Provider Business Mailing Address Fax Number:
352-728-3637

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
511 MEDICAL PLAZA DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEESBURG
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34748-7326
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-728-6808
Provider Business Practice Location Address Fax Number:
352-728-3637
Provider Enumeration Date:
06/17/2005

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: 207RC0000X , with the licence number:  ME74929 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RI0011X , with the licence number: ME 74929 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 695956 . This is a "TUFTS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7914953 . This is a "MAMSI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 01484956 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 773114 . This is a "MAILHANDLERS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 593516436003 . This is a "TRICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0108467 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00391218 . This is a "GBA RR PALMETTO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 92419 . This is a "BCBS FLORIDA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 113145800 . 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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