1073152088 NPI number — MEIRA DERMATOLOGY, LLC

Table of content: (NPI 1073152088)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073152088 NPI number — MEIRA DERMATOLOGY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEIRA DERMATOLOGY, 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:
1073152088
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/27/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8484 W GULF BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TREASURE ISLAND
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33706-3422
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-777-6098
Provider Business Mailing Address Fax Number:
727-888-6829

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8839 BRYAN DAIRY RD STE 115
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LARGO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33777-1207
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-777-6098
Provider Business Practice Location Address Fax Number:
727-888-6829
Provider Enumeration Date:
12/23/2019

Additional Information

Authorized Official

Authorized Official Last Name:
POHLER
Authorized Official First Name:
HOLLY
Authorized Official Middle Name:
FRANCES
Authorized Official Title or Position:
OWNER, AUTHORIZED OFFICIAL
Authorized Official Telephone Number:
727-777-6098

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LA2200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 105125000 . 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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