1144292913 NPI number — MONICA LYNN MCPHAIL-PRUITT MD

Table of content: MONICA LYNN MCPHAIL-PRUITT MD (NPI 1144292913)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144292913 NPI number — MONICA LYNN MCPHAIL-PRUITT MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCPHAIL-PRUITT
Provider First Name:
MONICA
Provider Middle Name:
LYNN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1144292913
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/13/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2401 FRIST BLVD
Provider Second Line Business Mailing Address:
#7, 9 & 10
Provider Business Mailing Address City Name:
FORT PIERCE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34950-4800
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
772-466-0088
Provider Business Mailing Address Fax Number:
772-460-8555

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6903 W COLONIAL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORLANDO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32818-6829
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-298-9900
Provider Business Practice Location Address Fax Number:
407-298-9920
Provider Enumeration Date:
02/06/2006

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: 207LP2900X , with the licence number:  ME88069 , 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: 267728800 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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