1235218405 NPI number — INFECTIOUS DISEASE GROUP, PA

Table of content: (NPI 1235218405)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235218405 NPI number — INFECTIOUS DISEASE GROUP, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INFECTIOUS DISEASE GROUP, PA
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:
1235218405
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/13/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1717 N E ST
Provider Second Line Business Mailing Address:
SUITE 439
Provider Business Mailing Address City Name:
PENSACOLA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32501-6339
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-432-3692
Provider Business Mailing Address Fax Number:
800-918-3765

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1717 N E ST
Provider Second Line Business Practice Location Address:
SUITE 439
Provider Business Practice Location Address City Name:
PENSACOLA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32501-6339
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-432-3692
Provider Business Practice Location Address Fax Number:
800-918-3765
Provider Enumeration Date:
11/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CLEMENTS
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
SIDNEY
Authorized Official Title or Position:
PRESIDENT OF CORPORATION
Authorized Official Telephone Number:
850-432-3692

Provider Taxonomy Codes

  • Taxonomy code: 207RI0200X , 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: 377030300 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 529502140 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 377030300 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com