1356821953 NPI number — TAYLOR ISAAC RUUD

Table of content: TAYLOR ISAAC RUUD (NPI 1356821953)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356821953 NPI number — TAYLOR ISAAC RUUD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUUD
Provider First Name:
TAYLOR
Provider Middle Name:
ISAAC
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1356821953
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/23/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/11/2019
NPI Reactivation Date:
03/18/2019

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7060 VENICE WAY APT 3106
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NAPLES
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34119-9626
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
435-704-4818
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
350 7TH ST N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NAPLES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34102-5754
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-624-5000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/14/2018

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: 367500000X , with the licence number:  APRN11001894 , 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: 102740600 . 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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