1649454752 NPI number — JUPITER MEDICAL GROUP P A

Table of content: (NPI 1649454752)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649454752 NPI number — JUPITER MEDICAL GROUP P A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JUPITER MEDICAL GROUP P A
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:
1649454752
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/26/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
875 MILITARY TRL
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
JUPITER
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33458-5700
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-746-2411
Provider Business Mailing Address Fax Number:
561-354-0012

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
601 UNIVERSITY BLVD
Provider Second Line Business Practice Location Address:
SUITE 204
Provider Business Practice Location Address City Name:
JUPITER
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33458-2788
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-746-2411
Provider Business Practice Location Address Fax Number:
561-354-0012
Provider Enumeration Date:
12/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BANSAL
Authorized Official First Name:
RAJENDRA
Authorized Official Middle Name:
K.
Authorized Official Title or Position:
MD
Authorized Official Telephone Number:
561-746-2411

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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