1366653545 NPI number — ONE SOURCE MEDICAL GROUP LLC

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 1366653545 NPI number — ONE SOURCE MEDICAL GROUP LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ONE SOURCE MEDICAL GROUP LLC
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:
1366653545
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/24/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13910 LYNMAR BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TAMPA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33626-3123
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-834-7473
Provider Business Mailing Address Fax Number:
877-490-9111

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13910 LYNMAR 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:
33626
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-792-3560
Provider Business Practice Location Address Fax Number:
877-490-9111
Provider Enumeration Date:
05/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ROBICHAUD
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
J
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
866-834-7473

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  1313496 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332BP3500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 032072200 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5703548 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 032072200 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com