1588095442 NPI number — MDLIVE MEDICAL GROUP OR LLC

Table of content: (NPI 1588095442)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588095442 NPI number — MDLIVE MEDICAL GROUP OR LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MDLIVE MEDICAL GROUP OR 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:
1588095442
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/03/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4350 FOWLER ST STE 21
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT MYERS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33901-2616
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
855-332-4499
Provider Business Mailing Address Fax Number:
231-932-4133

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13630 NW 8TH ST STE 205
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUNRISE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33325-6238
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
855-332-4499
Provider Business Practice Location Address Fax Number:
231-932-4133
Provider Enumeration Date:
12/03/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MOTARJEME
Authorized Official First Name:
STEVE
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGING PARTNER
Authorized Official Telephone Number:
855-332-4499

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 104100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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