1780762096 NPI number — PENEMARIE K MURPHY, INC

Table of content: (NPI 1780762096)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780762096 NPI number — PENEMARIE K MURPHY, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PENEMARIE K MURPHY, INC
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:
1780762096
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/17/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 11677
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32239-1677
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-745-0302
Provider Business Mailing Address Fax Number:
904-745-0750

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7001 MERRILL RD
Provider Second Line Business Practice Location Address:
SUITE 27
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32277-3005
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-744-0277
Provider Business Practice Location Address Fax Number:
904-744-0263
Provider Enumeration Date:
11/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MURPHY
Authorized Official First Name:
PENEMARIE
Authorized Official Middle Name:
KALLAS
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
904-645-7400

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  225100000X , 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: 880295500 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 162113800 . This is a "DEPT OF LABOR" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: Y909R . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 5490100 . This is a "AETNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 102330 . This is a "AVMED" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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