1780872705 NPI number — SURFSIDE FAMILY PRACTICE LLC

Table of content: (NPI 1780872705)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780872705 NPI number — SURFSIDE FAMILY PRACTICE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SURFSIDE FAMILY PRACTICE LLC
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:
1780872705
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/22/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3000 N ATLANTIC AVE
Provider Second Line Business Mailing Address:
SUITE 108
Provider Business Mailing Address City Name:
COCOA BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32931-5078
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-799-2554
Provider Business Mailing Address Fax Number:
321-799-4750

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3000 N ATLANTIC AVE
Provider Second Line Business Practice Location Address:
SUITE 108
Provider Business Practice Location Address City Name:
COCOA BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32931-5078
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-799-2554
Provider Business Practice Location Address Fax Number:
321-799-4750
Provider Enumeration Date:
10/04/2007

Additional Information

Authorized Official

Authorized Official Last Name:
EARLE
Authorized Official First Name:
HARRY
Authorized Official Middle Name:
ALLEN
Authorized Official Title or Position:
DOCTOR
Authorized Official Telephone Number:
321-799-2554

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  ME00059920 , 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: 055552599 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: AG997 . This is a "MEDICARE PTAN" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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