1710246483 NPI number — JAY PEDIATRICS PA

Table of content: (NPI 1710246483)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710246483 NPI number — JAY PEDIATRICS PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JAY PEDIATRICS 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:
MARIAN B STEWART MD
Provider Other Organization Name Type Code:
5
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:
1710246483
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/15/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 10
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JAY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32565-0010
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-675-4546
Provider Business Mailing Address Fax Number:
850-675-4548

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14088 ALABAMA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JAY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32565-1036
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-675-4546
Provider Business Practice Location Address Fax Number:
850-675-4548
Provider Enumeration Date:
05/15/2012

Additional Information

Authorized Official

Authorized Official Last Name:
STEWART
Authorized Official First Name:
MARIAN
Authorized Official Middle Name:
B
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
850-675-4546

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  ME68044 , 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: 264891884 . This is a "TRICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 32119 . This is a "BLUE CROSS AND BLUE SHIELD OF FLORIDA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 59176907 . This is a "BLUE CROSS AND BLUE SHIELD OF ALABAMA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1206338 . This is a "UNITED HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1202673 . This is a "COVENTRY" identifier . This identifiers is of the category "OTHER".
  • Identifier: 264891884 . This is a "HUMANA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 264891884 . This is a "CHAMPVA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 251076600 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4878883 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5173714 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 009905570 . This is a "ALACAID" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




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