1366835795 NPI number — MELBOURNE MEDICAL LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366835795 NPI number — MELBOURNE MEDICAL LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MELBOURNE MEDICAL 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:
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:
1366835795
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/10/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1600 W EAU GALLIE BLVD
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
MELBOURNE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32935-4149
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-751-3862
Provider Business Mailing Address Fax Number:
321-751-3865

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1600 W EAU GALLIE BLVD
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
MELBOURNE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32935-4149
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-751-3862
Provider Business Practice Location Address Fax Number:
321-751-3865
Provider Enumeration Date:
03/10/2015

Additional Information

Authorized Official

Authorized Official Last Name:
MERCER
Authorized Official First Name:
BILL
Authorized Official Middle Name:
Authorized Official Title or Position:
OPERATION MANAGER
Authorized Official Telephone Number:
321-751-3862

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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