1235323023 NPI number — LONGWOOD MEDICAL GROUP PA

Table of content: (NPI 1235323023)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235323023 NPI number — LONGWOOD MEDICAL GROUP PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LONGWOOD MEDICAL GROUP 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:
LONGWOOD CARDIOLOGY PA
Provider Other Organization Name Type Code:
4
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:
1235323023
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/01/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
04/15/2018
NPI Reactivation Date:
05/01/2018

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
450 W STATE RD 434
Provider Second Line Business Mailing Address:
STE 301
Provider Business Mailing Address City Name:
LONGWOOD
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32750
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-767-8200
Provider Business Mailing Address Fax Number:
407-767-0476

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
450 W STATE ROAD 434
Provider Second Line Business Practice Location Address:
STE 301
Provider Business Practice Location Address City Name:
LONGWOOD
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32750-5187
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-767-8200
Provider Business Practice Location Address Fax Number:
407-767-0476
Provider Enumeration Date:
09/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CHARACTER
Authorized Official First Name:
ALISA
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
BILLING OFFICE SUPERVISOR
Authorized Official Telephone Number:
407-767-8200

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  ME79324 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0000X , with the licence number: ME78066 , 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: 000082000 . 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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