1295730216 NPI number — AMPUTEE CLINIC, INC.

Table of content: (NPI 1295730216)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295730216 NPI number — AMPUTEE CLINIC, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AMPUTEE 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:
1295730216
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/30/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7051 CYPRESS TER
Provider Second Line Business Mailing Address:
#108
Provider Business Mailing Address City Name:
FORT MYERS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33907-8822
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-437-4010
Provider Business Mailing Address Fax Number:
239-437-4097

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7051 CYPRESS TER
Provider Second Line Business Practice Location Address:
#108
Provider Business Practice Location Address City Name:
FORT MYERS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33907-8822
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-437-4010
Provider Business Practice Location Address Fax Number:
239-437-4097
Provider Enumeration Date:
06/16/2005

Additional Information

Authorized Official

Authorized Official Last Name:
RANDALL
Authorized Official First Name:
MARCUM
Authorized Official Middle Name:
R
Authorized Official Title or Position:
PRESIDENT PT CP LPO
Authorized Official Telephone Number:
239-437-4010

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 335E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 009939684 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 81750 . This is a "NORTHWOOD (BC/BS MI DME)" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 204925600 . This is a "TVA" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 8150 . This is a "NORTHWOOD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1454256 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 52895744 001 . This is a "GEORGIA HEALTH PARTNERSHI" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 1295730216 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000914064A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 004016999 . This is a "BC/BS OF TN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 13125 . This is a "PHP, CARITEN, PHP TENNCAR" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 4016999 . This is a "BC/BS TN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 118139100 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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