1528489606 NPI number — PRIME PEDIATRICS OF CASSELBERRY

Table of content: (NPI 1528489606)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528489606 NPI number — PRIME PEDIATRICS OF CASSELBERRY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRIME PEDIATRICS OF CASSELBERRY
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:
1528489606
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/17/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8236 LEE VISTA BLVD
Provider Second Line Business Mailing Address:
STE I
Provider Business Mailing Address City Name:
ORLANDO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32829-8070
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-809-5562
Provider Business Mailing Address Fax Number:
407-809-5562

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3950 S HWY 17/92
Provider Second Line Business Practice Location Address:
STE 2024
Provider Business Practice Location Address City Name:
CASSELBERRY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32707-3295
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-809-5562
Provider Business Practice Location Address Fax Number:
407-809-5562
Provider Enumeration Date:
12/17/2013

Additional Information

Authorized Official

Authorized Official Last Name:
ELFAKI
Authorized Official First Name:
SALMA
Authorized Official Middle Name:
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
407-809-5562

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  ME101587 , 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)





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