1043375611 NPI number — NEUROLOGICAL DISORDERS CLINIC PA

Table of content: (NPI 1043375611)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043375611 NPI number — NEUROLOGICAL DISORDERS CLINIC PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEUROLOGICAL DISORDERS CLINIC 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:
1043375611
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/17/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
880 NW 13TH ST
Provider Second Line Business Mailing Address:
SUITE 3-B
Provider Business Mailing Address City Name:
BOCA RATON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33486-2342
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-394-0005
Provider Business Mailing Address Fax Number:
561-393-0048

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
880 NW 13TH ST
Provider Second Line Business Practice Location Address:
SUITE 3-B
Provider Business Practice Location Address City Name:
BOCA RATON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33486-2342
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-394-0005
Provider Business Practice Location Address Fax Number:
561-393-0048
Provider Enumeration Date:
12/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
NORONA
Authorized Official First Name:
FERNANO
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
561-394-0005

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  74877 , 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: 2338601 . This is a "AETNA HMO" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: WM988 . This is a "EMPIRE BC BS" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 032627 . This is a "NHP" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 2338601 . This is a "AETNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 49479Z . This is a "MEDICARE INDIVIDUAL" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".
  • Identifier: 1026677 . This is a "CARE PLU" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 49479 . This is a "BLUE SHIELD FL PROVIDER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 5890751 . This is a "AETNA NON HMO" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 74877 . This is a "FL LICENSE NUMBER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 004651200 . 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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