1609981083 NPI number — JUPITER FOOT AND ANKLE PA

Table of content: (NPI 1609981083)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609981083 NPI number — JUPITER FOOT AND ANKLE PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JUPITER FOOT AND ANKLE 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:
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:
1609981083
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/27/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
651 W INDIANTOWN ROAD
Provider Second Line Business Mailing Address:
SUITE K
Provider Business Mailing Address City Name:
JUPITER
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33458
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-741-4900
Provider Business Mailing Address Fax Number:
561-741-4918

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
651 W INDIANTOWN ROAD
Provider Second Line Business Practice Location Address:
SUITE K
Provider Business Practice Location Address City Name:
JUPITER
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33458
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-741-4900
Provider Business Practice Location Address Fax Number:
561-741-4918
Provider Enumeration Date:
08/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
VENA
Authorized Official First Name:
VIRGINIO
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER PRESIDENT
Authorized Official Telephone Number:
561-741-4900

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  PO2828 , 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: 3402606-00 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 340260600 . 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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