1922099555 NPI number — DR. RONALD LORIN SHAW MD

Table of content: DR. RONALD LORIN SHAW MD (NPI 1922099555)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922099555 NPI number — DR. RONALD LORIN SHAW MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHAW
Provider First Name:
RONALD
Provider Middle Name:
LORIN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1922099555
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/01/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10051 5TH ST N STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT PETERSBURG
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33702-2211
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-824-0780
Provider Business Mailing Address Fax Number:
727-568-6011

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2304 ALOMA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINTER PARK
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32792-3330
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-679-9222
Provider Business Practice Location Address Fax Number:
407-679-9061
Provider Enumeration Date:
11/02/2005

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: 207Q00000X , with the licence number:  ME0044966 , 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: C13264 . This is a "RAILROAD GROUP NUMBER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 069347200 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 220003327 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 593339550 . This is a "WINTER PARK FAMILY HEALTH CENTER, INC" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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