1124023445 NPI number — JOHN MICHAEL TIERNEY PA

Table of content: JOHN MICHAEL TIERNEY PA (NPI 1124023445)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124023445 NPI number — JOHN MICHAEL TIERNEY PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TIERNEY
Provider First Name:
JOHN
Provider Middle Name:
MICHAEL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
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:
1124023445
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/19/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1325 SAN MARCO BLVD STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32207-8566
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-346-3465
Provider Business Mailing Address Fax Number:
904-880-1210

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14540 OLD SAINT AUGUSTINE RD
Provider Second Line Business Practice Location Address:
SUITE 2201
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32258-7418
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-880-1260
Provider Business Practice Location Address Fax Number:
904-880-1210
Provider Enumeration Date:
06/14/2005

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: 363A00000X , with the licence number:  PA9102882 , 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: 292014000 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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