1225027493 NPI number — PROVIDENCE MEDICAL CORPORATION

Table of content: (NPI 1225027493)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225027493 NPI number — PROVIDENCE MEDICAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROVIDENCE MEDICAL CORPORATION
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:
1225027493
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/26/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 48833
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST PETERSBURG
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33743-8833
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-540-9377
Provider Business Mailing Address Fax Number:
727-540-9387

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3350 ULMERTON RD
Provider Second Line Business Practice Location Address:
SUITE 16
Provider Business Practice Location Address City Name:
CLEARWATER
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33762-3397
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-540-9377
Provider Business Practice Location Address Fax Number:
727-540-9387
Provider Enumeration Date:
10/19/2005

Additional Information

Authorized Official

Authorized Official Last Name:
LEVERING
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
RICHARD
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
727-540-9377

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  326 , 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: 022415400 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: R9114 . This is a "BCBS OF FLORIDA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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