1376636647 NPI number — DR. IDA MARIE EWEN PHD

Table of content: (NPI 1144373879)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376636647 NPI number — DR. IDA MARIE EWEN PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EWEN
Provider First Name:
IDA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHD
Provider Gender Code:
F

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:
1376636647
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/10/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6410 SPYGLASS LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRADENTON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34202-1707
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
941-484-5431
Provider Business Mailing Address Fax Number:
941-727-8005

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
901 VENETIA BAY BLVD
Provider Second Line Business Practice Location Address:
SUITE 358
Provider Business Practice Location Address City Name:
VENICE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34285-8041
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-484-5431
Provider Business Practice Location Address Fax Number:
941-727-8005
Provider Enumeration Date:
10/01/2006

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: 103T00000X , with the licence number:  00005326 , 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: 59801 . This is a "BLUE CROSS BLUE SHIELD ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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