1811186653 NPI number — JEFFREY S GORODETSKY MD PA

Table of content: (NPI 1811186653)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811186653 NPI number — JEFFREY S GORODETSKY MD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JEFFREY S GORODETSKY MD 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:
1811186653
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/17/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
433 E OCEAN BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STUART
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34994-2573
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
772-223-4504
Provider Business Mailing Address Fax Number:
772-223-5988

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
433 E OCEAN BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STUART
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34994-2573
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
772-223-4504
Provider Business Practice Location Address Fax Number:
772-223-5988
Provider Enumeration Date:
10/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GORODETSKY
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
S
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
772-223-4504

Provider Taxonomy Codes

  • Taxonomy code: 173000000X , with the licence number:  ME0053894 , 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: 07463 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: P00307631 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 048745701 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 07463P . This is a "MEDICARE INDIVIDUAL" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: K9632 . This is a "MEDICACE GROUP" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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