1619325784 NPI number — ADVANCED PEDIATRIC CARE

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619325784 NPI number — ADVANCED PEDIATRIC CARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCED PEDIATRIC CARE
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:
1619325784
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/15/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
943 CESERY BLVD BLDG G
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32211
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-861-1330
Provider Business Mailing Address Fax Number:
904-600-0402

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
943 CESERY BLVD BLDG G
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32211
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-861-1330
Provider Business Practice Location Address Fax Number:
904-600-0402
Provider Enumeration Date:
05/31/2016

Additional Information

Authorized Official

Authorized Official Last Name:
ALI
Authorized Official First Name:
NOORJAHAN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
904-861-1330

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  126160 , 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: 017614000 . 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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