1629276613 NPI number — ELLEN GORDON POAGE ARNP

Table of content: ELLEN GORDON POAGE ARNP (NPI 1629276613)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629276613 NPI number — ELLEN GORDON POAGE ARNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POAGE
Provider First Name:
ELLEN
Provider Middle Name:
GORDON
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ARNP
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:
1629276613
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/14/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2234 COLONIAL BLVD
Provider Second Line Business Mailing Address:
ATTN: PAYER CONTRACTING & RELATIONS
Provider Business Mailing Address City Name:
FORT MYERS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33907-1412
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-931-7342
Provider Business Mailing Address Fax Number:
239-931-7385

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8660 COLLEGE PKWY
Provider Second Line Business Practice Location Address:
SUITE 60
Provider Business Practice Location Address City Name:
FORT MYERS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33919-4886
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-277-0919
Provider Business Practice Location Address Fax Number:
239-415-4960
Provider Enumeration Date:
07/11/2007

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: 363LF0000X , with the licence number:  ARNP1812112 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: ARNP1812112 , 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: P01279998 . This is a "RAILROAD MCR" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: P959926 . This is a "OPTIMUM" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: Y4971 . This is a "BCBS OF FL" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: P999557 . This is a "FREEDOM" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 1235753 . This is a "WELLCARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 398633 . This is a "AVMED" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 5034309 . This is a "AETNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 308841300 . 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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