1750422184 NPI number — KAREN CHRISTIANE THEILADE MD

Table of content: KAREN CHRISTIANE THEILADE MD (NPI 1750422184)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750422184 NPI number — KAREN CHRISTIANE THEILADE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THEILADE
Provider First Name:
KAREN
Provider Middle Name:
CHRISTIANE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1750422184
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/30/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
120 CYPRESS EDGE DR
Provider Second Line Business Mailing Address:
SUITE 203
Provider Business Mailing Address City Name:
PALM COAST
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32164-8453
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-586-4410
Provider Business Mailing Address Fax Number:
386-445-3398

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 CYPRESS EDGE DR
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
PALM COAST
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32164-8453
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-586-4410
Provider Business Practice Location Address Fax Number:
386-445-3398
Provider Enumeration Date:
02/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  ME106807 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RI0011X , with the licence number: ME106807 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 14AA4 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 003120001 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: P01170719 . This is a "RAILROAD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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