1790973394 NPI number — NIGHT OWL PEDIATRICS PA

Table of content: (NPI 1790973394)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790973394 NPI number — NIGHT OWL PEDIATRICS PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NIGHT OWL 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:
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:
1790973394
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/11/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10359 CROSS CREEK BLVD STE CD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TAMPA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33647-2772
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-994-0044
Provider Business Mailing Address Fax Number:
813-994-0055

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10359 CROSS CREEK BLVD
Provider Second Line Business Practice Location Address:
SUITE CD
Provider Business Practice Location Address City Name:
TAMPA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33647-2772
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-994-0044
Provider Business Practice Location Address Fax Number:
813-994-0055
Provider Enumeration Date:
10/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ADS
Authorized Official First Name:
ASHRAF
Authorized Official Middle Name:
Authorized Official Title or Position:
PROVIDER / OWNER
Authorized Official Telephone Number:
734-306-2518

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  ME65878 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QU0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2080P0204X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000714800 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 375833800 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: B905P . This is a "BCBSFL" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: BL081Y . This is a "BCBSFL" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 117917800 . 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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