1700859048 NPI number — REBELLO MEDICAL ASSOCIATES MD PL

Table of content: (NPI 1700859048)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700859048 NPI number — REBELLO MEDICAL ASSOCIATES MD PL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
REBELLO MEDICAL ASSOCIATES MD PL
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:
1700859048
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/09/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13590 S JOG RD STE C3
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DELRAY BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33446-3807
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-637-8383
Provider Business Mailing Address Fax Number:
561-423-9253

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13590 JOG RD
Provider Second Line Business Practice Location Address:
SUITE C3
Provider Business Practice Location Address City Name:
DELRAY BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33446-3807
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-637-8383
Provider Business Practice Location Address Fax Number:
561-423-9253
Provider Enumeration Date:
02/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
REBELLO
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
IGNATIUS
Authorized Official Title or Position:
DOCTOR/OWNER
Authorized Official Telephone Number:
561-637-8383

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , 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: 114058400 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 007605800 . 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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