1790709111 NPI number — MICHAEL L ADIX DO

Table of content: MICHAEL L ADIX DO (NPI 1790709111)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790709111 NPI number — MICHAEL L ADIX DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ADIX
Provider First Name:
MICHAEL
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

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:
1790709111
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/11/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3152 LITTLE ROAD, SUITE 115
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TRINITY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34655
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-510-7536
Provider Business Mailing Address Fax Number:
727-494-7421

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
419 EARL ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHELBY
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28150
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-481-0555
Provider Business Practice Location Address Fax Number:
704-481-9169
Provider Enumeration Date:
07/27/2006

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: 207P00000X , with the licence number:  2011040029 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 9401112 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8910156 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: N01112 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 013295700 . 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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