1912927237 NPI number — MARY JOSEPHINE SUTHERLAND P.A.-C

Table of content: MARY JOSEPHINE SUTHERLAND P.A.-C (NPI 1912927237)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912927237 NPI number — MARY JOSEPHINE SUTHERLAND P.A.-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SUTHERLAND
Provider First Name:
MARY
Provider Middle Name:
JOSEPHINE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.A.-C
Provider Gender Code:
F

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:
1912927237
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3189 HIGHWAY 17
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREEN COVE SPRINGS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32043-9371
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-621-0247
Provider Business Mailing Address Fax Number:
904-339-9945

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3189 US HIGHWAY 17
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FLEMING ISLAND
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32003-7109
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-621-0247
Provider Business Practice Location Address Fax Number:
904-339-9945
Provider Enumeration Date:
07/20/2006

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: 363A00000X , with the licence number:  PA2225 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X , with the licence number: PA2225 , 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: 291115900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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