1386723005 NPI number — INDEPENDENT PEDIATRICIANS OF NORTH FL INC

Table of content: (NPI 1386723005)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386723005 NPI number — INDEPENDENT PEDIATRICIANS OF NORTH FL INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INDEPENDENT PEDIATRICIANS OF NORTH FL 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:
1386723005
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/08/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4051 ATLANTIC BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32207-2036
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-493-9702
Provider Business Mailing Address Fax Number:
904-493-9700

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4051 ATLANTIC BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32207-2036
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-493-9702
Provider Business Practice Location Address Fax Number:
904-493-9700
Provider Enumeration Date:
11/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TRESSLER
Authorized Official First Name:
PAULETTE
Authorized Official Middle Name:
L
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
904-493-9702

Provider Taxonomy Codes

  • Taxonomy code: 173000000X , with the licence number:  ME56953 , 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: 271318700 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 273107000 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 277263903 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 042374200 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 273661600 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: ME92233 . This is a "ME LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 055661101 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: ME57974 . This is a "ME LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 260365900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 277393700 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: ARNP3253072 . This is a "LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: ME100160 . This is a "ME LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: ME44431 . This is a "ME LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 277263900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: ME32409 . This is a "ME LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: ME56953 . This is a "ME LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: ME63783 . This is a "ME LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: ME91195 . This is a "ME LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 277263904 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 277263905 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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