1609265065 NPI number — DR. RUDOLPH PAVLESICH III DNP, CRNA, FNP-BC

Table of content: DR. RUDOLPH PAVLESICH III DNP, CRNA, FNP-BC (NPI 1609265065)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609265065 NPI number — DR. RUDOLPH PAVLESICH III DNP, CRNA, FNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PAVLESICH
Provider First Name:
RUDOLPH
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
III
Provider Credential Text:
DNP, CRNA, FNP-BC
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:
1609265065
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/17/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
89 STEVENS HILL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NOTTINGHAM
Provider Business Mailing Address State Name:
NH
Provider Business Mailing Address Postal Code:
03290-4802
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-535-1875
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16 HOSPITAL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PLYMOUTH
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03264-1126
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-536-1120
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/22/2015

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: 367500000X , with the licence number:  281215 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: ARNP9178468 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: 074985-23 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LF0000X , with the licence number: 2017019797 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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