1164161840 NPI number — INTERNAL MEDICINE LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164161840 NPI number — INTERNAL MEDICINE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTERNAL MEDICINE LLC
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:
6
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:
1164161840
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/16/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
450 W STATE ROAD 434 STE 1010
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LONGWOOD
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32750-5187
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
450 W STATE ROAD 434 STE 1010
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONGWOOD
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32750-5187
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-786-0004
Provider Business Practice Location Address Fax Number:
407-636-7689
Provider Enumeration Date:
06/01/2022

Additional Information

Authorized Official

Authorized Official Last Name:
JORDAN
Authorized Official First Name:
ANDY
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING SPECIALIST
Authorized Official Telephone Number:
321-206-8100

Provider Taxonomy Codes

  • Taxonomy code: 207RI0011X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 118140000 . 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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