1497758338 NPI number — MARILYN L JURICIC MD

Table of content: MARILYN L JURICIC MD (NPI 1497758338)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497758338 NPI number — MARILYN L JURICIC MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JURICIC
Provider First Name:
MARILYN
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1497758338
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/08/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
601 S HARBOUR ISLAND BLVD STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TAMPA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33602-5925
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-480-5243
Provider Business Mailing Address Fax Number:
800-928-7449

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1400 N US HIGHWAY 441 STE 912
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LADY LAKE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32159-6811
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-750-1277
Provider Business Practice Location Address Fax Number:
844-388-6186
Provider Enumeration Date:
05/24/2005

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: 207Q00000X , with the licence number:  ME 71383 , 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: 31631 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 018050900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00224863 . This is a "MEDICARD RAILROAD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 111994200 . 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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