1205278454 NPI number — MEDICAL & PSYCHIATRIC INSITIUTE OF FLORIDA, INC.

Table of content: (NPI 1205278454)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205278454 NPI number — MEDICAL & PSYCHIATRIC INSITIUTE OF FLORIDA, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDICAL & PSYCHIATRIC INSITIUTE OF FLORIDA, INC.
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:
1205278454
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/19/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
927 BEVILLE RD STE 7
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH DAYTONA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32119-1769
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-269-9009
Provider Business Mailing Address Fax Number:
386-269-9004

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6056 CENTRAL PARK BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORT ORANGE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32127-9539
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-216-4000
Provider Business Practice Location Address Fax Number:
386-676-2555
Provider Enumeration Date:
07/29/2013

Additional Information

Authorized Official

Authorized Official Last Name:
KHAN
Authorized Official First Name:
ASAD
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
304-216-4000

Provider Taxonomy Codes

  • Taxonomy code: 2084F0202X , with the licence number:  ME114528 , 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: 0116181000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0206560 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 010048200 . 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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