1588660658 NPI number — MAUREEN CLAIRE HOLASEK M.D.

Table of content: MAUREEN CLAIRE HOLASEK M.D. (NPI 1588660658)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588660658 NPI number — MAUREEN CLAIRE HOLASEK M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HOLASEK
Provider First Name:
MAUREEN
Provider Middle Name:
CLAIRE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1588660658
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/03/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 864460
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:
32886-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-243-9709
Provider Business Mailing Address Fax Number:
352-243-8703

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1920 DON WICKHAM DR
Provider Second Line Business Practice Location Address:
STE. 130
Provider Business Practice Location Address City Name:
CLERMONT
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34711-1918
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-243-9709
Provider Business Practice Location Address Fax Number:
352-243-8703
Provider Enumeration Date:
06/23/2005

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: 174400000X , with the licence number:  ME62103 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0001X , with the licence number: ME62103 , 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: P00470573 . This is a "RR MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 15050 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 212921 . This is a "AVMED" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 370683400 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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