1356538771 NPI number — OPTUM INFUSION SERVICES 204, INC.

Table of content: (NPI 1356538771)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356538771 NPI number — OPTUM INFUSION SERVICES 204, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OPTUM INFUSION SERVICES 204, 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:
1356538771
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/29/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
826 CREIGHTON RD
Provider Second Line Business Mailing Address:
UNIT A-103
Provider Business Mailing Address City Name:
PENSACOLA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32504
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-522-8438
Provider Business Mailing Address Fax Number:
844-246-1271

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
826 CREIGHTON RD
Provider Second Line Business Practice Location Address:
UNIT A103
Provider Business Practice Location Address City Name:
PENSACOLA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32504-7076
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
866-522-8438
Provider Business Practice Location Address Fax Number:
844-246-1271
Provider Enumeration Date:
09/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
OBERG
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
JOHN
Authorized Official Title or Position:
ASSISTANT SECRETARY
Authorized Official Telephone Number:
949-988-5893

Provider Taxonomy Codes

  • Taxonomy code: 3336C0004X , with the licence number:  PH27820 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336H0001X , with the licence number: PH22890 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336M0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336S0011X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 016048600 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1029215 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 016048600 . 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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