1811975725 NPI number — NORTH CENTRAL MEDICAL CORPORATION INC

Table of content: (NPI 1811975725)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811975725 NPI number — NORTH CENTRAL MEDICAL CORPORATION INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTH CENTRAL MEDICAL CORPORATION 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:
Provider Other Organization Name Type Code:
6
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:
1811975725
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/08/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 142098
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GAINESVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32614-2098
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-373-9656
Provider Business Mailing Address Fax Number:
352-374-4136

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4001 NEWBERRY RD
Provider Second Line Business Practice Location Address:
STE A2
Provider Business Practice Location Address City Name:
GAINESVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32607-2358
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-373-9656
Provider Business Practice Location Address Fax Number:
352-374-4136
Provider Enumeration Date:
01/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
THOMPSON
Authorized Official First Name:
JACK
Authorized Official Middle Name:
B
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
352-373-9656

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 009930935 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1164348 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7703365 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: DM1139 . This is a "SOUTH CAROLINA MEDICAID P" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 606429698A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 010070554 . This is a "VIRGINIA MEDICAL ASSISTAN" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 0440757 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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