1366478109 NPI number — ASANTE-KORANG EDWARDS GIROUD MARTINEZ MCCORMACK & SUH MD PA

Table of content: (NPI 1366478109)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366478109 NPI number — ASANTE-KORANG EDWARDS GIROUD MARTINEZ MCCORMACK & SUH MD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ASANTE-KORANG EDWARDS GIROUD MARTINEZ MCCORMACK & SUH MD 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:
1366478109
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/24/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
880 6TH ST S
Provider Second Line Business Mailing Address:
280
Provider Business Mailing Address City Name:
ST PETERSBURG
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33701-4827
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-767-4200
Provider Business Mailing Address Fax Number:
727-767-8047

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
840 DR MLKING JR ST NO
Provider Second Line Business Practice Location Address:
400
Provider Business Practice Location Address City Name:
ST PETERSBURG
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33705
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-767-4200
Provider Business Practice Location Address Fax Number:
727-767-8047
Provider Enumeration Date:
06/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MCCORMACK
Authorized Official First Name:
JORGE
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
727-767-4200

Provider Taxonomy Codes

  • Taxonomy code: 2080P0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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