1548779580 NPI number — SAMAR FAWAZ

Table of content: SAMAR FAWAZ (NPI 1548779580)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548779580 NPI number — SAMAR FAWAZ

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FAWAZ
Provider First Name:
SAMAR
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1548779580
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/31/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2065 HIGHWAY A1A APT 1403
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INDIAN HARBOUR BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32937-1811
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-574-2965
Provider Business Mailing Address Fax Number:
321-603-3560

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
175 VILLA NUEVA AVE NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PALM BAY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32907-2595
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-574-2965
Provider Business Practice Location Address Fax Number:
321-603-3560
Provider Enumeration Date:
09/21/2017

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: 363A00000X , with the licence number:  5601008292 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: PA9111341 , 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: P02091188 . This is a "RRMEDICARE PTAN" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 101048700 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: JL436Z . This is a "MEDICARE PTAN" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 101048700 . 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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