1902948466 NPI number — BARBARA C BUSTILLO-LEWIN PAC

Table of content: RAULDON OSCAR BOYCE RN (NPI 1316418668)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902948466 NPI number — BARBARA C BUSTILLO-LEWIN PAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BUSTILLO-LEWIN
Provider First Name:
BARBARA
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PAC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BUSTILLO
Provider Other First Name:
BARBARA
Provider Other Middle Name:
C
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1902948466
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3434 HANCOCK BRIDGE PKWY STE 301
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTH FORT MYERS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33903-7099
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-856-3774
Provider Business Mailing Address Fax Number:
239-599-2612

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14350 METROPOLIS AVE STE 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT MYERS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33912-4430
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-275-3036
Provider Business Practice Location Address Fax Number:
239-275-8480
Provider Enumeration Date:
02/13/2007

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:  PA9103319 , 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: 292731400 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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