1699764100 NPI number — SCG MADILL BROOKSIDE LLC

Table of content: (NPI 1699764100)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699764100 NPI number — SCG MADILL BROOKSIDE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SCG MADILL BROOKSIDE 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:
1699764100
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/17/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1240 MARBELLA PLAZA DR.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TAMPA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33619-7905
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-341-2700
Provider Business Mailing Address Fax Number:
813-676-0127

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
310 BROOKSIDE DR
Provider Second Line Business Practice Location Address:
HIGHWAY 377
Provider Business Practice Location Address City Name:
MADILL
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73446-9047
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-795-2100
Provider Business Practice Location Address Fax Number:
580-677-9918
Provider Enumeration Date:
10/18/2005

Additional Information

Authorized Official

Authorized Official Last Name:
GOYER
Authorized Official First Name:
KEVIN
Authorized Official Middle Name:
C
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
813-341-2700

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  NH4801-4801 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100776200A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com