1558622068 NPI number — GUTTERIDGE JEANCHARLES, MD, PA

Table of content: (NPI 1558622068)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558622068 NPI number — GUTTERIDGE JEANCHARLES, MD, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GUTTERIDGE JEANCHARLES, MD, PA
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:
6
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:
1558622068
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/29/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 617440
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORLANDO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32861
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-914-2325
Provider Business Mailing Address Fax Number:
407-826-1592

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1781 PARK CENTER DRIVE
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
ORLANDO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32835-6245
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-914-2325
Provider Business Practice Location Address Fax Number:
407-826-1592
Provider Enumeration Date:
05/31/2012

Additional Information

Authorized Official

Authorized Official Last Name:
JEANCHARLES
Authorized Official First Name:
GUTTERIDGE
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT/CEO/MEDICAL DIRECTOR
Authorized Official Telephone Number:
407-914-2325

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 008208900 . 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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