1821691726 NPI number — MICHAEL BOULOSWELSON FUAD

Table of content: MICHAEL BOULOSWELSON FUAD (NPI 1821691726)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821691726 NPI number — MICHAEL BOULOSWELSON FUAD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FUAD
Provider First Name:
MICHAEL
Provider Middle Name:
BOULOSWELSON
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

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:
1821691726
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/22/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1748 TRIBUTORY LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORT ORANGE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32128-4049
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
347-691-9001
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1800 NEW SYMRNA
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW SYMERNA BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32168
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-428-1558
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/21/2020

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  PS62086 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 183500000X , with the licence number: PH100003270 , registered in the state of DC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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