1336145663 NPI number — JESSE JUDELLE M.D.

Table of content: JESSE JUDELLE M.D. (NPI 1336145663)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336145663 NPI number — JESSE JUDELLE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JUDELLE
Provider First Name:
JESSE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1336145663
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/13/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1300 MEDICAL DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TALLAHASSEE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32308-4646
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-216-0100
Provider Business Mailing Address Fax Number:
850-216-0180

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1300 MEDICAL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TALLAHASSEE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32308-4646
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-216-0100
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/22/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  ME23983 , 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: 01092 . This is a "UNIVERSAL HEALTH CARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 051174900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00000 . This is a "MULTIPLAN NETWORK" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 00000 . This is a "UNITED HC" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 00000 . This is a "BC BS OF FLORIDA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 00000 . This is a "SOUTHCARE NETWORK" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 0000 . This is a "EVOUTIONS HC" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 00000 . This is a "BEECH ST/CAPP CARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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