1396975009 NPI number — ELLEN CHASE VAN MOL M.D.

Table of content: ELLEN CHASE VAN MOL M.D. (NPI 1396975009)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396975009 NPI number — ELLEN CHASE VAN MOL M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VAN MOL
Provider First Name:
ELLEN
Provider Middle Name:
CHASE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

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:
1396975009
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/09/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9914 EQUUS CIRCLE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOYNTON BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
60611-5359
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-296-6555
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1000 N OLIVE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST PALM BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33401-3512
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-557-1767
Provider Business Practice Location Address Fax Number:
561-327-5125
Provider Enumeration Date:
07/16/2009

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: 207R00000X , with the licence number:  ME112566 , 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: 116855600 . 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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