1336209568 NPI number — DAVITA MEDICAL FLORIDA, INC.

Table of content: (NPI 1336209568)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336209568 NPI number — DAVITA MEDICAL FLORIDA, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DAVITA MEDICAL FLORIDA, INC.
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:
DAVITA MEDICAL GROUP, PHARMACY
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:
1336209568
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/10/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10051 5TH STREET NORTH
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:
33702-2299
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-681-7888
Provider Business Mailing Address Fax Number:
813-661-0843

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1931 W LUMSDEN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRANDON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33511-8819
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-681-7888
Provider Business Practice Location Address Fax Number:
813-661-0843
Provider Enumeration Date:
12/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HILGER
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF ACCOUNTING OFFICER
Authorized Official Telephone Number:
253-973-0777

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  PH13061 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336M0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 030848000 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2013026 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4399230004 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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