1548345234 NPI number — MAVERICK MEDICAL VENTURES, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548345234 NPI number — MAVERICK MEDICAL VENTURES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAVERICK MEDICAL VENTURES, 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:
Provider Other Organization Name Type Code:
6
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:
1548345234
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3501 CATTLEMEN RD
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
SARASOTA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34232-6055
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
941-342-7667
Provider Business Mailing Address Fax Number:
941-342-7847

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3501 CATTLEMEN RD
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
SARASOTA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34232-6055
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-342-7667
Provider Business Practice Location Address Fax Number:
941-342-7847
Provider Enumeration Date:
10/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BAFIA
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
F
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
941-342-7667

Provider Taxonomy Codes

  • Taxonomy code: 261QR0200X , with the licence number:  HCC5056 , 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: 7180294 . This is a "AETNA PROVIDER NUMBER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 2013853 . This is a "FIRST HEALTH PROVIDER NUM" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 201694 . This is a "STAYWELL PROVIDER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 226521 . This is a "AMERIGROUP PROVIDER NUMBE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: V2973 . This is a "BCBS PROVIDER NUMBER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 5425850 . This is a "CCN PROVIDER NUMBER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 82030 . This is a "MEDICARE COMPLETE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: A2545060 . This is a "OXFORD PROVIDER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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