1699081067 NPI number — NORTH FLORIDA EYE CENTER PA

Table of content: (NPI 1699081067)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699081067 NPI number — NORTH FLORIDA EYE CENTER PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTH FLORIDA EYE CENTER PA
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:
1699081067
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/24/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
410 N MAIN ST
Provider Second Line Business Mailing Address:
SUITE 6
Provider Business Mailing Address City Name:
CHIEFLAND
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32626-0866
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-493-2634
Provider Business Mailing Address Fax Number:
352-493-2517

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
410 N MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 6
Provider Business Practice Location Address City Name:
CHIEFLAND
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32626-0866
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-493-2634
Provider Business Practice Location Address Fax Number:
352-493-2517
Provider Enumeration Date:
08/24/2010

Additional Information

Authorized Official

Authorized Official Last Name:
FANOUS
Authorized Official First Name:
MAHER
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
352-331-7337

Provider Taxonomy Codes

  • Taxonomy code: 156FX1800X , with the licence number:  OPC 4437 , 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: 49379 . This is a "BCBS OF FL" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 257002500 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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