1245273093 NPI number — HERNANDO PASCO PRIMARY CARE LLC

Table of content: (NPI 1245273093)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245273093 NPI number — HERNANDO PASCO PRIMARY CARE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HERNANDO PASCO PRIMARY CARE 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:
MYCARE MEDICAL
Provider Other Organization Name Type Code:
3
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:
1245273093
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20525 AMBERFIELD DR UNIT 104
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAND O LAKES
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34638-4381
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-702-1133
Provider Business Mailing Address Fax Number:
833-642-0635

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11373 CORTEZ BLVD
Provider Second Line Business Practice Location Address:
206
Provider Business Practice Location Address City Name:
BROOKSVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34613-5414
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-596-3032
Provider Business Practice Location Address Fax Number:
352-596-3066
Provider Enumeration Date:
06/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
NAVADIA
Authorized Official First Name:
SANJAY
Authorized Official Middle Name:
H
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
727-389-5146

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207QA0505X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 273533400 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: K5936 . This is a "MEDICARE ID (PTAN)" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: MY831 . This is a "MEDICARE ID (PTAN)" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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