1730593773 NPI number — SMH PHYSICIAN SERVICES INC

Table of content: (NPI 1730593773)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730593773 NPI number — SMH PHYSICIAN SERVICES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SMH PHYSICIAN SERVICES INC
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:
HERITAGE HARBOUR TIME SHARE OFFICE
Provider Other Organization Name Type Code:
5
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:
1730593773
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/13/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 863407
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORLANDO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32886-3407
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
941-917-2600
Provider Business Mailing Address Fax Number:
941-917-7884

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1040 RIVER HERITAGE BLVD
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
BRADENTON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34212-6348
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-917-2600
Provider Business Practice Location Address Fax Number:
941-917-7884
Provider Enumeration Date:
06/18/2014

Additional Information

Authorized Official

Authorized Official Last Name:
GILBERT-DROGE
Authorized Official First Name:
ILENE
Authorized Official Middle Name:
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
941-917-8700

Provider Taxonomy Codes

  • Taxonomy code: 207LP2900X , with the licence number:  ME111784 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: ME84613 , 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: 33181 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 376537700 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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