1679690366 NPI number — MR. MICHAEL R MEDVED PA

Table of content: MR. MICHAEL R MEDVED PA (NPI 1679690366)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679690366 NPI number — MR. MICHAEL R MEDVED PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MEDVED
Provider First Name:
MICHAEL
Provider Middle Name:
R
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
M

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:
1679690366
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/13/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3560 A1A S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT AUGUSTINE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32080-9731
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-584-2273
Provider Business Mailing Address Fax Number:
904-429-9783

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3560 A1A S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT AUGUSTINE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32080-9731
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-584-2273
Provider Business Practice Location Address Fax Number:
904-823-9394
Provider Enumeration Date:
03/26/2007

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: 363AM0700X , with the licence number:  PA3163 , 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: PA3163 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 109109700 . 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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