1720073216 NPI number — PHYSICIAN PROVIDERS GROUP PA

Table of content: (NPI 1720073216)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720073216 NPI number — PHYSICIAN PROVIDERS GROUP PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHYSICIAN PROVIDERS GROUP 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:
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:
1720073216
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/03/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1925
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LADY LAKE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32158-1925
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
523-553-4075
Provider Business Mailing Address Fax Number:
888-770-3208

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
305 S LINE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INVERNESS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34452-4605
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-344-4791
Provider Business Practice Location Address Fax Number:
352-344-3822
Provider Enumeration Date:
09/12/2005

Additional Information

Authorized Official

Authorized Official Last Name:
ULSETH
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
Authorized Official Title or Position:
MD/OWNER
Authorized Official Telephone Number:
352-344-4791

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 34759 . This is a "BLUE SHIELD PROV #" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 101621300 . 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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