1245234954 NPI number — BARTOW MEDICAL CLINIC PA

Table of content: (NPI 1245234954)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245234954 NPI number — BARTOW MEDICAL CLINIC PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BARTOW MEDICAL CLINIC 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:
1245234954
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/07/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2020 FLAMINGO DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BARTOW
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33830-4262
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
863-533-4104
Provider Business Mailing Address Fax Number:
863-533-4549

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2020 FLAMINGO DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BARTOW
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33830-4262
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-533-4104
Provider Business Practice Location Address Fax Number:
863-533-4549
Provider Enumeration Date:
06/09/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SAUNDERS
Authorized Official First Name:
ALICIA
Authorized Official Middle Name:
S
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
863-533-4104

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 110023571 . This is a "RAILROAD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 100557 . This is a "ARMED" identifier . This identifiers is of the category "OTHER".
  • Identifier: 205961 . This is a "AMERI GROUP" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 377295100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".