1679538664 NPI number — SANTA ROSA DE LIMA MEDICAL PA

Table of content: (NPI 1679538664)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679538664 NPI number — SANTA ROSA DE LIMA MEDICAL PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SANTA ROSA DE LIMA MEDICAL 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:
1679538664
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/27/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4916 SAN MARINO CIR
Provider Second Line Business Mailing Address:
C/O S. CALDERON, MD
Provider Business Mailing Address City Name:
LAKE MARY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32746-2608
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-268-5415
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1055 SAXON BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORANGE CITY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32763-8468
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-268-5415
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CALDERON
Authorized Official First Name:
SANTIAGO
Authorized Official Middle Name:
W.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
407-268-5415

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  ME70874 , 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: 150170 . This is a "HEALTHEASE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 94709 . This is a "BC/BS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 000830802 . This is a "HUMANA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 13935 . This is a "FL MEMORIAL HEALTH NETWOR" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 263393100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: CH6285 . This is a "RR MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com