1144339383 NPI number — MR. MATTHEW JAMES PALICKA ARNP

Table of content: MR. MATTHEW JAMES PALICKA ARNP (NPI 1144339383)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144339383 NPI number — MR. MATTHEW JAMES PALICKA ARNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PALICKA
Provider First Name:
MATTHEW
Provider Middle Name:
JAMES
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
ARNP
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:
1144339383
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/10/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6101 PINE RIDGE RD
Provider Second Line Business Mailing Address:
DESK 12/13
Provider Business Mailing Address City Name:
NAPLES
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34119-3900
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-263-0849
Provider Business Mailing Address Fax Number:
239-263-2376

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
399 9TH ST N
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
NAPLES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34102-5820
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-436-5634
Provider Business Practice Location Address Fax Number:
239-649-1290
Provider Enumeration Date:
08/30/2006

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: 363L00000X , with the licence number:  ARNP3209042 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 5018574 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: YQ4QT . This is a "BCBS FL" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 002474000 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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