1891098943 NPI number — ELIZABETH ANNE SHEPPARD P.A.

Table of content: ELIZABETH ANNE SHEPPARD P.A. (NPI 1891098943)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891098943 NPI number — ELIZABETH ANNE SHEPPARD P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHEPPARD
Provider First Name:
ELIZABETH
Provider Middle Name:
ANNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.A.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BALCER
Provider Other First Name:
ELIZABETH
Provider Other Middle Name:
ANNE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
P.A.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1891098943
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/14/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3300 S FISKE BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCKLEDGE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32955-4306
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-434-9528
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8725 N WICKHAM RD STE 202
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MELBOURNE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32940-2240
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-434-9528
Provider Business Practice Location Address Fax Number:
321-434-9529
Provider Enumeration Date:
12/13/2010

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: 363A00000X , with the licence number:  PA9105602 , 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: NR566 . This is a "FL MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 003181500 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: PA9105602 . This is a "LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 003181500 . 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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