1114963006 NPI number — PAUL E GREGOLINE DPM PA

Table of content: (NPI 1114963006)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114963006 NPI number — PAUL E GREGOLINE DPM PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PAUL E GREGOLINE DPM PA
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:
1114963006
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/08/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1865 S OCEAN DR
Provider Second Line Business Mailing Address:
15 I
Provider Business Mailing Address City Name:
HALLANDALE BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33009-7603
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-457-5539
Provider Business Mailing Address Fax Number:
954-457-5539

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
45 NW 4TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOMESTEAD
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33030-5941
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
786-259-3239
Provider Business Practice Location Address Fax Number:
305-246-8556
Provider Enumeration Date:
06/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GREGOLINE
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
EUGENE
Authorized Official Title or Position:
PODIATRIC SURGEON
Authorized Official Telephone Number:
954-793-2387

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  PO2877 , 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: 340156101 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: DN9281 . This is a "RAILROAD MEDICARE NUMBER GROUP" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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