1609969302 NPI number — HERNANDO HMA LLC

Table of content: (NPI 1609969302)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609969302 NPI number — HERNANDO HMA LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HERNANDO HMA LLC
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:
HERNANDO ENDOSCOPY & SURGERY CENTER
Provider Other Organization Name Type Code:
3
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:
1609969302
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/14/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12180 CORTEZ BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROOKSVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34613
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-596-4999
Provider Business Mailing Address Fax Number:
352-596-2769

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12180 CORTEZ BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKSVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34613
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-596-4999
Provider Business Practice Location Address Fax Number:
352-596-2769
Provider Enumeration Date:
10/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KANURI
Authorized Official First Name:
DAMODAR
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
352-596-4999

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  1037 , 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: 6AT . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 003213900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 490003238 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 593354295 . This is a "UNITED HEALTHCARE OF FL" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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