1629650841 NPI number — JMG MEDICAL ASSOCIATES LLC

Table of content: (NPI 1629650841)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629650841 NPI number — JMG MEDICAL ASSOCIATES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JMG MEDICAL ASSOCIATES LLC
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:
1629650841
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/31/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2160 58TH AVE # 240
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VERO BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32966-4647
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
845-803-9267
Provider Business Mailing Address Fax Number:
772-202-7102

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1600 37TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VERO BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32960-4863
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
845-803-9267
Provider Business Practice Location Address Fax Number:
772-202-7102
Provider Enumeration Date:
04/27/2021

Additional Information

Authorized Official

Authorized Official Last Name:
GERARD
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
M
Authorized Official Title or Position:
ORGANISER
Authorized Official Telephone Number:
845-803-9267

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 110362500 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com