1770865917 NPI number — IRA FIALKO DO PA

Table of content: (NPI 1770865917)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770865917 NPI number — IRA FIALKO DO PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IRA FIALKO DO 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:
PREMIER PEDIATRICS COASTAL
Provider Other Organization Name Type Code:
3
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:
1770865917
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/12/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7960 SW 60TH AVE STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OCALA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34476-6409
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-671-6741
Provider Business Mailing Address Fax Number:
352-671-6742

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6171 W GULF TO LAKE HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CRYSTAL RIVER
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34429-2679
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-563-0220
Provider Business Practice Location Address Fax Number:
352-563-0706
Provider Enumeration Date:
09/14/2011

Additional Information

Authorized Official

Authorized Official Last Name:
EUNUS
Authorized Official First Name:
SHAHAB
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
352-671-6741

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  OS4404 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 121610464236 . This is a "HUMANA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 202840 . This is a "STAYWELL" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 046778200 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 82630 . This is a "BCBS OF FLORIDA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 267066600 . This is a "FLORIDA MEDICAID GROUP #" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 01118033 . This is a "AMERIGROUP" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 202840 . This is a "HEALTHEASE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 366272 . This is a "MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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