1104218940 NPI number — MRS. HOPE BRIDWELL POOLE NP

Table of content: MRS. HOPE BRIDWELL POOLE NP (NPI 1104218940)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104218940 NPI number — MRS. HOPE BRIDWELL POOLE NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POOLE
Provider First Name:
HOPE
Provider Middle Name:
BRIDWELL
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
NP
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:
1104218940
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/13/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1300 MEDICAL DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TALLAHASSEE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32308-4646
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-216-0100
Provider Business Mailing Address Fax Number:
850-216-0180

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4230 HOSPITAL DRIVE
Provider Second Line Business Practice Location Address:
HUDNALL BUILDING
Provider Business Practice Location Address City Name:
MARIANNA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32442
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-482-2205
Provider Business Practice Location Address Fax Number:
850-482-3691
Provider Enumeration Date:
03/03/2015

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: 363L00000X , with the licence number:  ARNP9324434 , 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: 014823800 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com