1053790717 NPI number — FLORIDA NERVE MED, LLC

Table of content: (NPI 1053790717)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053790717 NPI number — FLORIDA NERVE MED, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FLORIDA NERVE MED, LLC
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:
1053790717
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/20/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6400 N ANDREWS AVE
Provider Second Line Business Mailing Address:
SUITE 530
Provider Business Mailing Address City Name:
FORT LAUDERDALE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33309-2114
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
844-636-3876
Provider Business Mailing Address Fax Number:
561-429-3630

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6400 N ANDREWS AVE
Provider Second Line Business Practice Location Address:
SUITE 530
Provider Business Practice Location Address City Name:
FORT LAUDERDALE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33309-2114
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
844-636-3876
Provider Business Practice Location Address Fax Number:
561-429-3630
Provider Enumeration Date:
05/27/2015

Additional Information

Authorized Official

Authorized Official Last Name:
GEISSE
Authorized Official First Name:
HILDEGARDE
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER/ OWNER
Authorized Official Telephone Number:
561-310-7759

Provider Taxonomy Codes

  • Taxonomy code: 332BC3200X , with the licence number:  ME96190 , 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: 145ZC . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 6985656 . This is a "CIGNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 331981 . This is a "AVMED" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 9711158 . This is a "AETNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 46-1674338 . This is a "UHC" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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