1336405521 NPI number — JEFFERY J. KROMOLICKI PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336405521 NPI number — JEFFERY J. KROMOLICKI PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JEFFERY J. KROMOLICKI 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:
1336405521
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/10/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2019 LITTLE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TRINITY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34655-4421
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-375-7557
Provider Business Mailing Address Fax Number:
727-375-9958

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2019 LITTLE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TRINITY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34655-4421
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-375-7557
Provider Business Practice Location Address Fax Number:
727-375-9958
Provider Enumeration Date:
04/02/2012

Additional Information

Authorized Official

Authorized Official Last Name:
KROMOLICKI
Authorized Official First Name:
JEFFERY
Authorized Official Middle Name:
JOSEPH
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
727-375-7557

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  CH7844 , 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: 1881668077 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: E6152 . This is a "MEDICARE IDENTIFICATION NUMBER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 54009 . This is a "BSBSF" identifier . This identifiers is of the category "OTHER".




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