1578632147 NPI number — DR. GERALD A NIEDZWIECKI MD

Table of content: DR. GERALD A NIEDZWIECKI MD (NPI 1578632147)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578632147 NPI number — DR. GERALD A NIEDZWIECKI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NIEDZWIECKI
Provider First Name:
GERALD
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1578632147
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/09/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2730 N MCMULLEN BOOTH RD
Provider Second Line Business Mailing Address:
STE 100
Provider Business Mailing Address City Name:
CLEARWATER
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33761-3302
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-791-7300
Provider Business Mailing Address Fax Number:
727-723-9010

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2730 N MCMULLEN BOOTH RD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
CLEARWATER
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33761-3325
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-791-7300
Provider Business Practice Location Address Fax Number:
727-723-9010
Provider Enumeration Date:
11/07/2006

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: 2085R0202X , with the licence number:  ME0070649 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0204X , with the licence number: ME0070649 , 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: 250195300 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4595565 . This is a "AETNA PPO" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 1600774 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 2648373 . This is a "AETNA HMO" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 31439 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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