1922117845 NPI number — STAR SPORTS MEDICINE PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922117845 NPI number — STAR SPORTS MEDICINE PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STAR SPORTS MEDICINE 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:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1922117845
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/20/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 30010
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PENSACOLA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32503-1010
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-479-3320
Provider Business Mailing Address Fax Number:
850-479-8789

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9400 UNIVERSITY PKWY
Provider Second Line Business Practice Location Address:
SUITE 309
Provider Business Practice Location Address City Name:
PENSACOLA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32514-5752
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-479-3320
Provider Business Practice Location Address Fax Number:
850-479-8789
Provider Enumeration Date:
08/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DECAMPOS
Authorized Official First Name:
JULIET
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
850-479-3320

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 253484300 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: DG3210 . This is a "MEDICARE RAILROAD" identifier . This identifiers is of the category "OTHER".




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