1124028915 NPI number — NEUROLOGIC CONSULTANTS, PA

Table of content: (NPI 1124028915)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124028915 NPI number — NEUROLOGIC CONSULTANTS, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEUROLOGIC CONSULTANTS, PA
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:
1124028915
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/23/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
517 RIVIERA ST
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
VENICE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34285-2827
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
941-412-1208
Provider Business Mailing Address Fax Number:
941-412-1248

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
517 RIVIERA ST
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
VENICE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34285-2827
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-412-1208
Provider Business Practice Location Address Fax Number:
941-412-1248
Provider Enumeration Date:
07/22/2005

Additional Information

Authorized Official

Authorized Official Last Name:
ANCHETA
Authorized Official First Name:
JULLIUS
Authorized Official Middle Name:
ILAO
Authorized Official Title or Position:
PRESIDENT/PHYSICIAN
Authorized Official Telephone Number:
941-412-1208

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X , with the licence number:  ME80512 , 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: 264553000 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 58680 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com