1639151160 NPI number — BERRYHILL MEDICAL PL

Table of content: (NPI 1639151160)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639151160 NPI number — BERRYHILL MEDICAL PL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BERRYHILL MEDICAL PL
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:
BERRYHILL MEDICAL PLAZA LLC
Provider Other Organization Name Type Code:
4
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:
1639151160
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/20/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4785 N 9TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PENSACOLA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32503-2497
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-476-9691
Provider Business Mailing Address Fax Number:
850-476-0777

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4785 N 9TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PENSACOLA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32503-2497
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-476-9691
Provider Business Practice Location Address Fax Number:
850-476-0777
Provider Enumeration Date:
11/18/2005

Additional Information

Authorized Official

Authorized Official Last Name:
VERNALI
Authorized Official First Name:
LISBETH
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
850-476-9691

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  ME65994 , 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: 258620701 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 258620700 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 59083579 . This is a "BCBS AL" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 45147 . This is a "BC BS FL" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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