1659446425 NPI number — DIGESTIVE AND LIVER CENTER OF MELBOURNE LLC

Table of content: (NPI 1659446425)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659446425 NPI number — DIGESTIVE AND LIVER CENTER OF MELBOURNE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIGESTIVE AND LIVER CENTER OF MELBOURNE 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:
1659446425
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/22/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
25 SILVER PALM AVE
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
MELBOURNE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32901-3177
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-725-4150
Provider Business Mailing Address Fax Number:
321-733-1335

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
25 E SILVER PALM AVE
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
MELBOURNE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32901-3177
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-725-4150
Provider Business Practice Location Address Fax Number:
321-733-1335
Provider Enumeration Date:
11/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FARID
Authorized Official First Name:
MAGED
Authorized Official Middle Name:
DOSS
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
321-752-5210

Provider Taxonomy Codes

  • Taxonomy code: 261QE0800X , with the licence number:  1165 , 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: 075356400 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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