1427046085 NPI number — ELISA KRILL-JACKSON MD

Table of content: ELISA KRILL-JACKSON MD (NPI 1427046085)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427046085 NPI number — ELISA KRILL-JACKSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KRILL-JACKSON
Provider First Name:
ELISA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1427046085
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/31/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1475 NW 12TH AVE FL 32
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIAMI
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33136-1002
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-243-5302
Provider Business Mailing Address Fax Number:
305-243-9161

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1475 NW 12TH AVE FL 32
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIAMI
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33136-1002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-243-5302
Provider Business Practice Location Address Fax Number:
305-243-9161
Provider Enumeration Date:
10/07/2005

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: 207RH0003X , with the licence number:  0066352 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 174400000X , with the licence number: ME66352 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RH0003X , with the licence number: ME66352 , 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: 272074400 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".