1902076524 NPI number — MONROSE CLINIC ASSOCIATES FOR PSYCHOLOGICAL MEDICINE

Table of content: (NPI 1902076524)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902076524 NPI number — MONROSE CLINIC ASSOCIATES FOR PSYCHOLOGICAL MEDICINE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MONROSE CLINIC ASSOCIATES FOR PSYCHOLOGICAL MEDICINE
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:
1902076524
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/17/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3627 UNIVERSITY BLVD S STE 615
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32216-7401
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-725-6463
Provider Business Mailing Address Fax Number:
904-724-5006

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3627 UNIVERSITY BLVD SOUTH SUITE 615
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32216-2721
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-725-6463
Provider Business Practice Location Address Fax Number:
904-724-5006
Provider Enumeration Date:
03/11/2008

Additional Information

Authorized Official

Authorized Official Last Name:
SHAH
Authorized Official First Name:
ATUL
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PSYCHIATRISTS
Authorized Official Telephone Number:
904-725-6463

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  ME0048902 , 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: 081686072 . This is a "TRICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 081686072 . This is a "CHAMPUS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 4115015 . This is a "AETNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 14203 . This is a "BLUE CROSS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 016627000 . This is a "MAGELLAN" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 05770 . This is a "WELLCARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 043765400 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 05770 . This is a "UNITED BEHAVIORAL HEALTH" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 081686072 . This is a "FIRST HEALTH" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 088657 . This is a "VALUE OPTIONS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 256262286A . This is a "GA. MEDICAID" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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