1669767109 NPI number — DR. STELIOS REKKAS MD

Table of content: DR. STELIOS REKKAS MD (NPI 1669767109)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669767109 NPI number — DR. STELIOS REKKAS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REKKAS
Provider First Name:
STELIOS
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
REKKAS
Provider Other First Name:
STELIO
Provider Other Middle Name:
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1669767109
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
367 S. GULPH RD
Provider Second Line Business Mailing Address:
ATT IPM CREDENTIALING
Provider Business Mailing Address City Name:
KING OF PRUSSIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19406-3121
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
775-356-9393
Provider Business Mailing Address Fax Number:
775-356-5590

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
232 MANATEE AVENUE EAST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRADENTON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34208-1932
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-254-4957
Provider Business Practice Location Address Fax Number:
941-254-4958
Provider Enumeration Date:
06/13/2011

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: 208600000X , with the licence number:  110761 , 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: 006798500 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 14M8R . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 117017800 . 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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