1508002072 NPI number — PEDIATRIC ENT, LLC

Table of content: (NPI 1508002072)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508002072 NPI number — PEDIATRIC ENT, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEDIATRIC ENT, 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:
FAMILY ENT & AUDIOLOGY
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:
1508002072
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/18/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1499 S HARBOR CITY BLVD STE 303
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MELBOURNE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32901-3245
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-254-5437
Provider Business Mailing Address Fax Number:
321-254-4543

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1499 S HARBOR CITY BLVD STE 303
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MELBOURNE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32901-3245
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-254-5437
Provider Business Practice Location Address Fax Number:
321-254-4543
Provider Enumeration Date:
01/05/2009

Additional Information

Authorized Official

Authorized Official Last Name:
MALIS
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
JOEL
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
321-254-5437

Provider Taxonomy Codes

  • Taxonomy code: 207YP0228X , with the licence number:  ME90348 , 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: 01269821 . This is a "MEDICAID HMO - AMERIGROUP" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 2258392 . This is a "MEDICAID HMO - UNITED HEALTH CARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 332181 . This is a "MEDICAID HMO - WELLCARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 271247400 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 115741600 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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