1801899026 NPI number — MEDFUND LLC

Table of content: (NPI 1801899026)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801899026 NPI number — MEDFUND LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDFUND LLC
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:
1801899026
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/10/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
240 N WASHINGTON BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SARASOTA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34236-5945
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
941-925-3490
Provider Business Mailing Address Fax Number:
941-953-4452

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3795 W BOYNTON BEACH BLVD
Provider Second Line Business Practice Location Address:
STE C
Provider Business Practice Location Address City Name:
BOYNTON BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33436-4502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-740-0221
Provider Business Practice Location Address Fax Number:
561-740-9305
Provider Enumeration Date:
05/23/2005

Additional Information

Authorized Official

Authorized Official Last Name:
KERN
Authorized Official First Name:
MARTIN
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
SENIOR VICE PRESIDENT
Authorized Official Telephone Number:
941-925-3490

Provider Taxonomy Codes

  • Taxonomy code: 261QM1200X , with the licence number:  HCC5193 , 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: V2311 . This is a "BCBS PROVIDER NUMBER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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