1447210257 NPI number — MR. JEFFREY THOMAS SPENCER CRNA

Table of content: MR. JEFFREY THOMAS SPENCER CRNA (NPI 1447210257)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447210257 NPI number — MR. JEFFREY THOMAS SPENCER CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SPENCER
Provider First Name:
JEFFREY
Provider Middle Name:
THOMAS
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
CRNA
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:
1447210257
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/11/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
86648 RIVERWOOD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
YULEE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32097-6446
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-307-5981
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4800 BELFORT RD
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:
32256-6004
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-483-5850
Provider Business Practice Location Address Fax Number:
904-265-6409
Provider Enumeration Date:
03/24/2006

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: 367500000X , with the licence number:  ARNP9173128 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 367500000X , with the licence number: APRN231221 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 306738600 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 414335265A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 112810900 . 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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