1184805830 NPI number — ADVANCED FAMILY MEDICINE CLINIC INC

Table of content: (NPI 1184805830)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184805830 NPI number — ADVANCED FAMILY MEDICINE CLINIC INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCED FAMILY MEDICINE CLINIC INC
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:
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:
1184805830
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/17/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
04/10/2020
NPI Reactivation Date:
04/17/2020

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
327 MEDCREST DRIVE
Provider Second Line Business Mailing Address:
UNIT A
Provider Business Mailing Address City Name:
CRESTVIEW
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32536
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-423-0761
Provider Business Mailing Address Fax Number:
855-793-3568

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
327 MEDCREST DRIVE
Provider Second Line Business Practice Location Address:
UNIT A
Provider Business Practice Location Address City Name:
CRESTVIEW
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32536
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-423-0761
Provider Business Practice Location Address Fax Number:
855-793-3568
Provider Enumeration Date:
11/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LOPS
Authorized Official First Name:
KATE
Authorized Official Middle Name:
R
Authorized Official Title or Position:
OWNER/PHYSICIAN
Authorized Official Telephone Number:
850-423-0761

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  ME89643 , 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: 1184805830 . This is a "TRICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 37798 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 1184805830 . This is a "HUMANA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 1184803830 . This is a "AETNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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