1184071730 NPI number — MR. BRUCE BRIAN BEARDSLEY JR. ARNP

Table of content: MR. BRUCE BRIAN BEARDSLEY JR. ARNP (NPI 1184071730)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184071730 NPI number — MR. BRUCE BRIAN BEARDSLEY JR. ARNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BEARDSLEY
Provider First Name:
BRUCE
Provider Middle Name:
BRIAN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
JR.
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:
1184071730
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/30/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5623 ORTEGA FARMS BLVD
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:
32244-2335
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-994-2706
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12058 SAN JOSE BLVD
Provider Second Line Business Practice Location Address:
STE 1003
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32223-8667
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-321-9875
Provider Business Practice Location Address Fax Number:
904-321-9890
Provider Enumeration Date:
05/24/2016

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: 363LP0808X , with the licence number:  ARNP9273193 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LF0000X , with the licence number: 9273193 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 108369900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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