1154317204 NPI number — MEDERI OF PALM BEACH COUNTY, INC.

Table of content: (NPI 1154317204)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154317204 NPI number — MEDERI OF PALM BEACH COUNTY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDERI OF PALM BEACH COUNTY, INC.
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:
1154317204
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9510 ORMSBY STATION RD
Provider Second Line Business Mailing Address:
STE 300
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40223-4081
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-891-1000
Provider Business Mailing Address Fax Number:
502-891-8067

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4723 W ATLANTIC AVE
Provider Second Line Business Practice Location Address:
STE A14
Provider Business Practice Location Address City Name:
DELRAY BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33445-3895
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-381-1077
Provider Business Practice Location Address Fax Number:
561-496-0357
Provider Enumeration Date:
09/23/2005

Additional Information

Authorized Official

Authorized Official Last Name:
GUENTHNER
Authorized Official First Name:
C.
Authorized Official Middle Name:
STEVEN
Authorized Official Title or Position:
SR VP, CFO
Authorized Official Telephone Number:
502-891-1000

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  20693096 , 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: H57 . This is a "BLUE CROSS-BLUE SHIELD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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