1891756904 NPI number — MS. KERRI L ELFVIN PA

Table of content: MS. KERRI L ELFVIN PA (NPI 1891756904)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891756904 NPI number — MS. KERRI L ELFVIN PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELFVIN
Provider First Name:
KERRI
Provider Middle Name:
L
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
F

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:
1891756904
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/17/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 44008
Provider Second Line Business Mailing Address:
UFJP PROVIDER ENROLLMENT
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32231-4008
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-244-3199
Provider Business Mailing Address Fax Number:
904-244-3425

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1833 BOULEVARD
Provider Second Line Business Practice Location Address:
UFJP - DEPT. OF CHFM/ SHANDS TOTAL CARE CLINIC
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32206-4382
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-383-1040
Provider Business Practice Location Address Fax Number:
904-244-8952
Provider Enumeration Date:
03/29/2006

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: 363A00000X , with the licence number:  PA1993 , 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: 313840618B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2906457-00 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 290645700 . 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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