1164662912 NPI number — SPACE COAST SURGERY CENTER LLC

Table of content: DR. JOSEPH W KEITH D.C. (NPI 1114353075)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164662912 NPI number — SPACE COAST SURGERY CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPACE COAST SURGERY CENTER 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:
1164662912
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/01/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
595 N COURTENAY PKWY STE 103
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MERRITT ISLAND
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32953-4852
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-890-1800
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
595 N COURTENAY PKWY
Provider Second Line Business Practice Location Address:
103
Provider Business Practice Location Address City Name:
MERRITT ISLAND
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32953-4851
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-569-6500
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/05/2009

Additional Information

Authorized Official

Authorized Official Last Name:
BALDOCK
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
B
Authorized Official Title or Position:
OFFICER AND AUTHORIZED OFFICIAL
Authorized Official Telephone Number:
615-234-5954

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 115245900 . 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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