1538147665 NPI number — SANDRA KAYE ARCHIBALD MD

Table of content: SANDRA KAYE ARCHIBALD MD (NPI 1538147665)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538147665 NPI number — SANDRA KAYE ARCHIBALD MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ARCHIBALD
Provider First Name:
SANDRA
Provider Middle Name:
KAYE
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:
1538147665
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/03/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1340 RIDGEWOOD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOLLY HILL
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32117
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-615-4001
Provider Business Mailing Address Fax Number:
386-676-7167

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
461 S NOVA RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORMOND BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32174
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-587-4421
Provider Business Practice Location Address Fax Number:
502-361-9947
Provider Enumeration Date:
01/09/2006

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: 207P00000X , with the licence number:  35509 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207P00000X , with the licence number: 104271 , 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: 64025554 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1131059 . This is a "PASSPORT" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 930097462 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000000057678 . This is a "ANTHEM GROUP NUMBER" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 029882600 . This is a "FEDERAL BLACK LUNG GROUP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 200301090A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 104430000 . 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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