1861495087 NPI number — MEDFUND LLC

Table of content: DR. REBECCA HAVEL PRUST D.D.S. (NPI 1609905645)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861495087 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:
1861495087
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
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:
951-953-4452

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6220 MANATEE AVE W
Provider Second Line Business Practice Location Address:
STE 101
Provider Business Practice Location Address City Name:
BRADENTON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34209-2303
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-761-8594
Provider Business Practice Location Address Fax Number:
941-761-3815
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:  HCC5210 , 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: V2645 . This is a "BCBS PROVIDER NUMBER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 3411979 . This is a "AETNA HMO PROVIDER NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5079697 . This is a "AETNA PPO/POS PROV NUMBER" identifier . This identifiers is of the category "OTHER".




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