1871546689 NPI number — NEUROLOGY INSTITUTE OF MELBOURNE PA

Table of content: (NPI 1871546689)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871546689 NPI number — NEUROLOGY INSTITUTE OF MELBOURNE PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEUROLOGY INSTITUTE OF MELBOURNE 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:
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Provider Other Credential Text:
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NPI Number Information

NPI Number:
1871546689
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/17/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 459
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MELBOURNE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32902-0459
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-725-6999
Provider Business Mailing Address Fax Number:
321-725-6981

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
116 SILVER PALM AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MELBOURNE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32901-3172
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-725-6999
Provider Business Practice Location Address Fax Number:
321-725-6981
Provider Enumeration Date:
05/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
UNGER
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
MAHLON
Authorized Official Title or Position:
OWNER/PHYSICIAN
Authorized Official Telephone Number:
321-725-6999

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X , with the licence number:  ME80168 , 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: 259417000 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 35458 . This is a "BLUE CROSS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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