1629006127 NPI number — JOSEPH W NYSTROM MD

Table of content: JOSEPH W NYSTROM MD (NPI 1629006127)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629006127 NPI number — JOSEPH W NYSTROM MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NYSTROM
Provider First Name:
JOSEPH
Provider Middle Name:
W
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1629006127
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/06/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7213 GREEN SLOPE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ZEPHYRHILLS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33541-1306
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-355-4914
Provider Business Mailing Address Fax Number:
855-547-5415

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7213 GREEN SLOPE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ZEPHYRHILLS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33541-1306
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-355-4914
Provider Business Practice Location Address Fax Number:
855-547-5415
Provider Enumeration Date:
06/30/2006

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: 207Q00000X , with the licence number:  ME69859 , 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: 080150384 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 379238200 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 28412 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 101954000 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com