1427074780 NPI number — MARK B VANCE D.O.

Table of content: MARK B VANCE D.O. (NPI 1427074780)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427074780 NPI number — MARK B VANCE D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VANCE
Provider First Name:
MARK
Provider Middle Name:
B
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
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:
1427074780
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/30/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2147
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT MYERS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33902-2147
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-424-2755
Provider Business Mailing Address Fax Number:
239-424-2756

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
708 DEL PRADO BLVD S STE 6
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CAPE CORAL
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33990
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-424-2755
Provider Business Practice Location Address Fax Number:
239-424-2756
Provider Enumeration Date:
07/13/2006

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: 208600000X , with the licence number:  OS15765 , 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: 101721600 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 114592330 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5251032 . This is a "BLUE CARE NETWORK" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 5251032 . This is a "BLUE CROSS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 7420565 . This is a "AETNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0998650 . This is a "GENESEE HEALTH PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 139094 . This is a "PREFERRED CHOICE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 382626202 . This is a "CARE CHOICES" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0998650 . This is a "HEALTH PLUS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0N89830001 . This is a "BLUE CROSS MEDICARE ADVAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1427074780 . This is a "HEALTH ALLIANCE PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: P00271698 . This is a "PALMETTO GBA - RR MEDICAR" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1015760 . This is a "MCLAREN HEALTH PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 16587 . This is a "MCARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 101721600 . 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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