1558622068 NPI number — GUTTERIDGE JEANCHARLES, MD, PA

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 1558622068 NPI number — GUTTERIDGE JEANCHARLES, MD, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GUTTERIDGE JEANCHARLES, MD, 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:
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:
1558622068
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/29/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 617440
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORLANDO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32861
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-914-2325
Provider Business Mailing Address Fax Number:
407-826-1592

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1781 PARK CENTER DRIVE
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
ORLANDO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32835-6245
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-914-2325
Provider Business Practice Location Address Fax Number:
407-826-1592
Provider Enumeration Date:
05/31/2012

Additional Information

Authorized Official

Authorized Official Last Name:
JEANCHARLES
Authorized Official First Name:
GUTTERIDGE
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT/CEO/MEDICAL DIRECTOR
Authorized Official Telephone Number:
407-914-2325

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 008208900 . 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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