1689819534 NPI number — DR. JOSEPH BOLANAN SALENGA M.D.

Table of content: (NPI 1164280319)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689819534 NPI number — DR. JOSEPH BOLANAN SALENGA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SALENGA
Provider First Name:
JOSEPH
Provider Middle Name:
BOLANAN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1689819534
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/04/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8773 PERIMETER PARK CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32216-1165
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-493-3390
Provider Business Mailing Address Fax Number:
904-493-3395

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8773 PERIMETER PARK CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32216-1165
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-493-3390
Provider Business Practice Location Address Fax Number:
904-493-3395
Provider Enumeration Date:
12/06/2008

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: 207R00000X , with the licence number:  261577 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: ME114390 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208M00000X , with the licence number: ME114390 , 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: 003174381A . This is a "GEORGIA MEDICAID" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: P01202783 . This is a "RR MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 14P3S . This is a "FLORIDA BLUE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 45681 . This is a "MEDICARE - GROUP" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 786594 . This is a "WELLCARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 0083955-00 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2610299-00 . This is a "MEDICAID GROUP" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 363224 . This is a "AVMED" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: GY389Z . This is a "MEDICARE - INDIVIDUAL" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 112466100 . 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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