1477556413 NPI number — MELISSA PE SIROIS AUD

Table of content: MELISSA PE SIROIS AUD (NPI 1477556413)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477556413 NPI number — MELISSA PE SIROIS AUD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SIROIS
Provider First Name:
MELISSA
Provider Middle Name:
PE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
AUD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PE
Provider Other First Name:
MELISSA
Provider Other Middle Name:
OLIVEROS
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1477556413
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1600 LAKELAND HILLS BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKELAND
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33805-3019
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
863-680-7000
Provider Business Mailing Address Fax Number:
866-264-8519

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2300 E. COUNTY ROAD 540A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKELAND
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33813-3825
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-904-6296
Provider Business Practice Location Address Fax Number:
866-264-8519
Provider Enumeration Date:
05/23/2005

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: 231H00000X , with the licence number:  AY1139 , 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: 002398500 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".