1104895473 NPI number — GREGORY F MACISAAC MD

Table of content: GREGORY F MACISAAC MD (NPI 1104895473)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104895473 NPI number — GREGORY F MACISAAC MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MACISAAC
Provider First Name:
GREGORY
Provider Middle Name:
F
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1104895473
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/12/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
120 CYPRESS EDGE DR
Provider Second Line Business Mailing Address:
SUITE 210
Provider Business Mailing Address City Name:
PALM COAST
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32164-8453
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-445-4750
Provider Business Mailing Address Fax Number:
386-445-4751

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 CYPRESS EDGE DR
Provider Second Line Business Practice Location Address:
SUITE 210
Provider Business Practice Location Address City Name:
PALM COAST
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32164-8453
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-445-4750
Provider Business Practice Location Address Fax Number:
386-445-4751
Provider Enumeration Date:
03/17/2006

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: 207Q00000X , with the licence number:  0101057756 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: ME119474 . This is a "FL MEDICAL LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 005620589 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 218728 . This is a "ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 103888600 . 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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