1275520603 NPI number — PATRICK E RONAN PAC

Table of content: LOURDES RAMOS (NPI 1386119923)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275520603 NPI number — PATRICK E RONAN PAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RONAN
Provider First Name:
PATRICK
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PAC
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:
1275520603
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/08/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
900 S PINE ISLAND RD
Provider Second Line Business Mailing Address:
SUITE 800
Provider Business Mailing Address City Name:
PLANTATION
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33324-3920
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
772-336-2818
Provider Business Mailing Address Fax Number:
772-336-5313

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1850 SW FOUNTAINVIEW BLVD
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
PORT ST LUCIE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34986
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
772-336-2818
Provider Business Practice Location Address Fax Number:
772-336-5313
Provider Enumeration Date:
09/30/2005

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: 363A00000X , with the licence number:  25MP00083900 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: PA9103651 , 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: 292376900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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