1528097284 NPI number — LEAVITT MEDICAL ASSOCIATES OF FLORIDA INC

Table of content: DEBRA JEDEIKIN M.A. LMFT (NPI 1285863084)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528097284 NPI number — LEAVITT MEDICAL ASSOCIATES OF FLORIDA INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LEAVITT MEDICAL ASSOCIATES OF FLORIDA INC
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:
ADVANCED DERMATOLOGY AND COSMETIC SURGERY
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:
1528097284
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/29/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
151 SOUTHHALL LN
Provider Second Line Business Mailing Address:
STE 300
Provider Business Mailing Address City Name:
MAITLAND
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32751-7233
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-875-2080
Provider Business Mailing Address Fax Number:
407-650-3455

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 INTERNATIONAL PKWY
Provider Second Line Business Practice Location Address:
240
Provider Business Practice Location Address City Name:
HEATHROW
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32746-5031
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-333-4200
Provider Business Practice Location Address Fax Number:
407-829-6637
Provider Enumeration Date:
07/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DECLUE
Authorized Official First Name:
AMY
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF PROVIDER SERVICES
Authorized Official Telephone Number:
407-875-2080

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  OS5365 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207ND0101X , with the licence number: OS5365 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207ND0900X , with the licence number: OS5365 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207NP0225X , with the licence number: OS5365 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207NS0135X , with the licence number: OS5365 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: OS5365 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RA0201X , with the licence number: OS5365 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208200000X , with the licence number: OS5365 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: OS5365 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 256877200 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 256877248 . 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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