1154647915 NPI number — MR. PHILIP ANDREW RUNFELDT BCABA

Table of content: MR. PHILIP ANDREW RUNFELDT BCABA (NPI 1154647915)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154647915 NPI number — MR. PHILIP ANDREW RUNFELDT BCABA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUNFELDT
Provider First Name:
PHILIP
Provider Middle Name:
ANDREW
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
BCABA
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:
1154647915
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/19/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 410286
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MELBOURNE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32941-0286
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-441-3925
Provider Business Mailing Address Fax Number:
800-728-0287

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
550 SAINT JOHNS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COCOA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32922-7241
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-639-9800
Provider Business Practice Location Address Fax Number:
321-639-6007
Provider Enumeration Date:
04/19/2010

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: 103K00000X , with the licence number:  0-09-3692 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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