1124090832 NPI number — FLORIDA DEPARTMENT OF HEALTH

Table of content: (NPI 1124090832)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124090832 NPI number — FLORIDA DEPARTMENT OF HEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FLORIDA DEPARTMENT OF HEALTH
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:
1124090832
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1105 E KENNEDY BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TAMPA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33602-3511
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-559-4344
Provider Business Mailing Address Fax Number:
813-276-2999

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1105 E KENNEDY BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TAMPA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33602-3511
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-559-4344
Provider Business Practice Location Address Fax Number:
813-276-2999
Provider Enumeration Date:
02/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MCNEIL
Authorized Official First Name:
SUZETTE
Authorized Official Middle Name:
Authorized Official Title or Position:
QUALITY ANALYST
Authorized Official Telephone Number:
813-559-4344

Provider Taxonomy Codes

  • Taxonomy code: 251K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00077128 . This is a "MEDICARE IDENTIFICATION NUMBER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 055726900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 99661 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 055726900 . 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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