1467434076 NPI number — MR. MATTHEW L MAROLD APRN

Table of content: MR. MATTHEW L MAROLD APRN (NPI 1467434076)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467434076 NPI number — MR. MATTHEW L MAROLD APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MAROLD
Provider First Name:
MATTHEW
Provider Middle Name:
L
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
APRN
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:
1467434076
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/20/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3300 S FISKE BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCKLEDGE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32955-4306
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-434-1401
Provider Business Mailing Address Fax Number:
321-434-1667

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1350 HICKORY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MELBOURNE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32901-3224
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-434-1401
Provider Business Practice Location Address Fax Number:
321-434-1667
Provider Enumeration Date:
11/18/2005

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: 363L00000X , with the licence number:  APRN2941622 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LA2200X , with the licence number: APRN2941622 , 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: Y050JU . This is a "HFPSI MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: Y050JT . This is a "FL MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 269581201 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 016031600 . 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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