1437562642 NPI number — PERFORMSPECIALTY, LLC

Table of content: (NPI 1437562642)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437562642 NPI number — PERFORMSPECIALTY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PERFORMSPECIALTY, 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:
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:
1437562642
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/19/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 STEVENS DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19113-1520
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2416 LAKE ORANGE DR
Provider Second Line Business Practice Location Address:
SUTIE 190
Provider Business Practice Location Address City Name:
ORLANDO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32837-7812
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-956-1220
Provider Business Practice Location Address Fax Number:
844-489-9565
Provider Enumeration Date:
06/05/2014

Additional Information

Authorized Official

Authorized Official Last Name:
TOOTLE
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
E
Authorized Official Title or Position:
ASSISTANT SECRETARY
Authorized Official Telephone Number:
215-937-8561

Provider Taxonomy Codes

  • Taxonomy code: 3336S0011X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 012043200 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1029314380001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 012043200 . 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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