1659339497 NPI number — TIM IOANNIDES MD LLC

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 1659339497 NPI number — TIM IOANNIDES MD LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TIM IOANNIDES MD 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:
6
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:
1659339497
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/22/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
140 SW CHAMBER CT
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
PORT ST LUCIE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34986-3414
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
772-878-3376
Provider Business Mailing Address Fax Number:
772-879-9970

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
140 SW CHAMBER CT
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
PORT ST LUCIE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34986-3414
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
772-878-3376
Provider Business Practice Location Address Fax Number:
772-879-9970
Provider Enumeration Date:
05/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
IOANNIDES
Authorized Official First Name:
TIM
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
772-878-3376

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 74907 . This is a "BCBS GROUP #" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: DA2154 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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