1902872062 NPI number — MATTHEW LAMAR MCCOUCHA CRNA NURSE ASSISTANT

Table of content: (NPI 1205036290)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902872062 NPI number — MATTHEW LAMAR MCCOUCHA CRNA NURSE ASSISTANT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCCOUCHA
Provider First Name:
MATTHEW
Provider Middle Name:
LAMAR
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA NURSE ASSISTANT
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:
1902872062
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/09/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1040 GULF BREEZE PARKWAY
Provider Second Line Business Mailing Address:
ANDREWS INSTITUTE FOR ORTHOPAEDICS & SPORTS MEDICINE
Provider Business Mailing Address City Name:
GULF BREEZE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32561
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-916-8700
Provider Business Mailing Address Fax Number:
850-916-8509

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
NAVAL HOSPITAL GREAT LAKES, 3001 A 6TH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREAT LAKES
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60088
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-688-3450
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/27/2006

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: 367500000X , with the licence number:  0024140275 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: ARNP9296655 , 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: 113428000 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".