1528308095 NPI number — TRICOUNTY SPECIALISTS LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528308095 NPI number — TRICOUNTY SPECIALISTS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRICOUNTY SPECIALISTS 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:
1528308095
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/26/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
510 CR 466
Provider Second Line Business Mailing Address:
SUITE 207
Provider Business Mailing Address City Name:
LADY LAKE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32159
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-240-1146
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
510 CR 466
Provider Second Line Business Practice Location Address:
SUITE 207
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-240-1146
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/21/2013

Additional Information

Authorized Official

Authorized Official Last Name:
MAXFIELD
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
S
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
352-240-1146

Provider Taxonomy Codes

  • Taxonomy code: 204D00000X , with the licence number:  ME15266 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 204D00000X , with the licence number: ME52212 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: ME15266 . This is a "NPI 1134186935" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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