1174732051 NPI number — DR. TARA CALABRESE MASSINI MD

Table of content: DR. TARA CALABRESE MASSINI MD (NPI 1174732051)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174732051 NPI number — DR. TARA CALABRESE MASSINI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MASSINI
Provider First Name:
TARA
Provider Middle Name:
CALABRESE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CALABRESE
Provider Other First Name:
TARA
Provider Other Middle Name:
MICHELLE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1174732051
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/27/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1601 SW ARCHER RD
Provider Second Line Business Mailing Address:
NF/SG VAMC DEPARTMENT OF RADIOLOGY
Provider Business Mailing Address City Name:
GAINESVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32608-1135
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-376-1611
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1600 SW ARCHER RD
Provider Second Line Business Practice Location Address:
DEPARTMENT OF RADIOLOGY, BOX 100374
Provider Business Practice Location Address City Name:
GAINESVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32610-3003
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-265-0291
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/21/2007

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: 2085R0202X , with the licence number:  TRN11157 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: ME 109703 , 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: 005941100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".