1154360642 NPI number — NICHOLAS OSWALD IANNOTTI MD, FACP

Table of content: NICHOLAS OSWALD IANNOTTI MD, FACP (NPI 1154360642)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154360642 NPI number — NICHOLAS OSWALD IANNOTTI MD, FACP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
IANNOTTI
Provider First Name:
NICHOLAS
Provider Middle Name:
OSWALD
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD, FACP
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:
1154360642
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/15/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1871 SE TIFFANY AVE
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
PORT ST LUCIE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34952-7585
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
772-335-5666
Provider Business Mailing Address Fax Number:
772-335-4826

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1871 SE TIFFANY AVE
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
PORT ST LUCIE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34952-7585
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
772-335-5666
Provider Business Practice Location Address Fax Number:
772-335-4826
Provider Enumeration Date:
06/06/2006

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: 207RH0003X , with the licence number:  0054918 , 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: 08210 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 830003199 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 0054918 . This is a "STATE LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 064733100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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