1548588262 NPI number — MR. MICHAEL JOHN DALE PA-C

Table of content: MR. MICHAEL JOHN DALE PA-C (NPI 1548588262)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548588262 NPI number — MR. MICHAEL JOHN DALE PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DALE
Provider First Name:
MICHAEL
Provider Middle Name:
JOHN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

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:
1548588262
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/07/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 25487
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SARASOTA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34277-2487
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
941-202-5342
Provider Business Mailing Address Fax Number:
855-253-4836

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6110 S.R. 70 EAST (53RD AVE)
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRADENTON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34203
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-755-4242
Provider Business Practice Location Address Fax Number:
941-755-1906
Provider Enumeration Date:
05/05/2010

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: 363AM0700X , with the licence number:  PA 9105384 , 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: Y0F6V . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 008214900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: PA9105384 . This is a "FL PHYSICIAN ASSISTANT LICENSE NUMBER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 107473100 . 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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