1154589786 NPI number — MEREDITH LYNN SHADDIX DO

Table of content: MEREDITH LYNN SHADDIX DO (NPI 1154589786)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154589786 NPI number — MEREDITH LYNN SHADDIX DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHADDIX
Provider First Name:
MEREDITH
Provider Middle Name:
LYNN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KNORSKY
Provider Other First Name:
MEREDITH
Provider Other Middle Name:
LYNN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DO
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1154589786
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/17/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5153 NORTH 9TH AVENUE
Provider Second Line Business Mailing Address:
SUITE 305
Provider Business Mailing Address City Name:
PENSACOLA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32504
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-416-6159
Provider Business Mailing Address Fax Number:
850-416-7198

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5153 NORTH 9TH AVENUE
Provider Second Line Business Practice Location Address:
SUITE 305
Provider Business Practice Location Address City Name:
PENSACOLA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32504
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-416-6159
Provider Business Practice Location Address Fax Number:
850-416-7198
Provider Enumeration Date:
05/30/2008

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: 2086S0127X , with the licence number:  OS13143 , 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: 111253100 . 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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