1174563449 NPI number — MARK C STINE DO

Table of content: MARK C STINE DO (NPI 1174563449)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174563449 NPI number — MARK C STINE DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STINE
Provider First Name:
MARK
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1174563449
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/11/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13787 BELCHER RD S
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
LARGO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33771-4065
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-535-9899
Provider Business Mailing Address Fax Number:
727-535-2818

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13787 BELCHER RD S
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
LARGO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33771-4065
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-535-9899
Provider Business Practice Location Address Fax Number:
727-535-2818
Provider Enumeration Date:
06/07/2006

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: 207R00000X , with the licence number:  OS5690 , 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: 372049700 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 011274200 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com