1316904022 NPI number — MICHAEL D PENTALERI M.D.

Table of content: MICHAEL D PENTALERI M.D. (NPI 1316904022)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316904022 NPI number — MICHAEL D PENTALERI M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PENTALERI
Provider First Name:
MICHAEL
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1316904022
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/29/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 102222
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30368-2222
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
392-748-2002
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3402 W DR MARTIN LUTHER KING JR BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TAMPA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33607-6214
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-875-3950
Provider Business Practice Location Address Fax Number:
813-872-2741
Provider Enumeration Date:
04/27/2006

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: 174400000X , with the licence number:  ME78641 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: ME78641 , 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: P00301196 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 35376 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: P01130437 . This is a "RR MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 259013100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003156073A . This is a "GA MEDICAID" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 301630 . This is a "AVMED" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 259013100 . 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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