1275518284 NPI number — HERMAN R MATALLANA DO PA

Table of content: (NPI 1275518284)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275518284 NPI number — HERMAN R MATALLANA DO PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HERMAN R MATALLANA DO 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:
6
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:
1275518284
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/14/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5420 STRICKLAND AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKELAND
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33812-4264
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
863-701-9510
Provider Business Mailing Address Fax Number:
863-701-9518

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5420 STRICKLAND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKELAND
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33812-4264
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-701-9510
Provider Business Practice Location Address Fax Number:
863-701-9518
Provider Enumeration Date:
12/13/2005

Additional Information

Authorized Official

Authorized Official Last Name:
MATALLANA
Authorized Official First Name:
HERMAN
Authorized Official Middle Name:
R
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
863-701-9510

Provider Taxonomy Codes

  • Taxonomy code: 207YS0123X , with the licence number:  OS7773 , 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: 208891 . This is a "HEALTHEASE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 227021 . This is a "AMERIGROUP" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 264722200 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9261729 . This is a "PHCS PRIVATE HEALTHCARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: V0004901 . This is a "CITRUSCAID" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 287598 . This is a "AVMED" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: N208891 . This is a "STAYWELL" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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