1093026619 NPI number — FLORIDA ATLANTIC UNIVERSITY

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093026619 NPI number — FLORIDA ATLANTIC UNIVERSITY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FLORIDA ATLANTIC UNIVERSITY
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:
6
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:
1093026619
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/14/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1650 OSCEOLA DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST PALM BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33409
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-803-8880
Provider Business Mailing Address Fax Number:
877-409-1795

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1650 OSCEOLA DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST PALM BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33409
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-803-8880
Provider Business Practice Location Address Fax Number:
877-409-1795
Provider Enumeration Date:
06/29/2010

Additional Information

Authorized Official

Authorized Official Last Name:
PONTIROLI KELLY
Authorized Official First Name:
LOUISA
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
561-803-8880

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0808X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 002Z8 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: K3331C . This is a "MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 303078400 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 681903 . This is a "FQHC MEDICARE 2021 FOR BOTH 1650 AND 720 LOCATIONS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 112255000 . This is a "FQHC MEDICAID 2021 FOR 1650 ONLY" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 303078411 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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