1164911913 NPI number — ERIC LANG POOVEY ARNP

Table of content: ERIC LANG POOVEY ARNP (NPI 1164911913)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164911913 NPI number — ERIC LANG POOVEY ARNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POOVEY
Provider First Name:
ERIC
Provider Middle Name:
LANG
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ARNP
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:
1164911913
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/08/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6118 WOODSIDE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32210-3949
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-994-0429
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
BAPTIST HEART SPECIALISTS
Provider Second Line Business Practice Location Address:
836 PRUDENTIAL DRIVE SUITE 1700
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32207
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-720-0799
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/08/2018

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: 363L00000X , with the licence number:  ARNP3367362 , 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: 025012900 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".