1558453662 NPI number — MCGOWAN SPINAL REHABILITATION CENTER PA

Table of content: (NPI 1558453662)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558453662 NPI number — MCGOWAN SPINAL REHABILITATION CENTER PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MCGOWAN SPINAL REHABILITATION CENTER PA
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:
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:
1558453662
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 17809
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32245-7809
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-723-0015
Provider Business Mailing Address Fax Number:
904-338-0951

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3021 MAIN ST N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32206-6168
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-350-5544
Provider Business Practice Location Address Fax Number:
904-350-9944
Provider Enumeration Date:
09/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MCGOWAN
Authorized Official First Name:
SHELITA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
904-350-5544

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  CH8235 , 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: 40249 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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