1912011222 NPI number — DR. SUSAN D FLAGEL D.O.

Table of content: DR. SUSAN D FLAGEL D.O. (NPI 1912011222)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912011222 NPI number — DR. SUSAN D FLAGEL D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FLAGEL
Provider First Name:
SUSAN
Provider Middle Name:
D
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BURN
Provider Other First Name:
SUSAN
Provider Other Middle Name:
D
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DO
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1912011222
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/25/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2675 WINKLER AVE FL 2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT MYERS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33901-9342
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-856-3774
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2572 COMMERCE PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTH PORT
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34289-9356
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-429-3545
Provider Business Practice Location Address Fax Number:
941-429-3546
Provider Enumeration Date:
08/17/2006

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: 208000000X , with the licence number:  3757 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: 381 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: OS 10992 , 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: IK203Y . This is a "MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 32137 . This is a "WELLMARK BLUE SHIELD" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 1579250 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 021026500 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0579250 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 27579 . This is a "WELLMARK BLUE SHIELD" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 149Q6 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 118317500 . 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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