1457428005 NPI number — FLEMING ISLAND SURGERY CENTER

Table of content: (NPI 1457428005)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457428005 NPI number — FLEMING ISLAND SURGERY CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FLEMING ISLAND SURGERY CENTER
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:
1457428005
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1670 EAGLE HARBOR PKWY
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
ORANGE PARK
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32003-4806
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-541-3048
Provider Business Mailing Address Fax Number:
904-215-7960

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1670 EAGLE HARBOR PKWY
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
ORANGE PARK
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32003-4806
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-541-3048
Provider Business Practice Location Address Fax Number:
904-215-7960
Provider Enumeration Date:
11/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MCLAUGHLIN
Authorized Official First Name:
TARA
Authorized Official Middle Name:
SHEA
Authorized Official Title or Position:
DIRECTOR OF CONTRACTING
Authorized Official Telephone Number:
727-785-9800

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  PENDING , 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: PENDING . This is a "STATE LICENSE NUMBER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 105529000 . 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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