1972812279 NPI number — BETH A LILJESTRAND MS EDS

Table of content: BETH A LILJESTRAND MS EDS (NPI 1972812279)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972812279 NPI number — BETH A LILJESTRAND MS EDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LILJESTRAND
Provider First Name:
BETH
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MS EDS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SLANE
Provider Other First Name:
BETH
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MS EDS
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1972812279
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/18/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3233 ARBOR HILL WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TALLAHASSEE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32309
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-661-5466
Provider Business Mailing Address Fax Number:
850-894-0062

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3201 SHAMROCK ST S
Provider Second Line Business Practice Location Address:
STE 103
Provider Business Practice Location Address City Name:
TALLAHASSEE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32309-3321
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-661-5466
Provider Business Practice Location Address Fax Number:
850-894-0062
Provider Enumeration Date:
10/04/2010

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: 101Y00000X , with the licence number:  MH7203 , 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: 008302000 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 004814600 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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