1033263207 NPI number — KATHLEEN LOUISE PAVEL PA

Table of content: KATHLEEN LOUISE PAVEL PA (NPI 1033263207)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033263207 NPI number — KATHLEEN LOUISE PAVEL PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PAVEL
Provider First Name:
KATHLEEN
Provider Middle Name:
LOUISE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
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:
1033263207
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/15/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2315 W JACKSON ST
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:
32505-7552
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-436-4630
Provider Business Mailing Address Fax Number:
850-436-2095

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5855 CREEK STATION DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PENSACOLA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32504-8626
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-435-4352
Provider Business Practice Location Address Fax Number:
850-497-6195
Provider Enumeration Date:
01/23/2007

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: 363AM0700X , with the licence number:  PA9110987 , 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: LP952 . This is a "MCR FL" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: PENDING , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 592-40194 . This is a "BCBS AL" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: P4ZXN . This is a "BCBS FL" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 103858100 . 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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