1952547507 NPI number — KRISHNA M GANTI MD PA

Table of content: (NPI 1952547507)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952547507 NPI number — KRISHNA M GANTI MD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KRISHNA M GANTI MD PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1952547507
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/29/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11373 CORTEZ BLVD
Provider Second Line Business Mailing Address:
SUITE 203
Provider Business Mailing Address City Name:
BROOKSVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34613-5414
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-596-6158
Provider Business Mailing Address Fax Number:
352-596-6186

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11373 CORTEZ BLVD
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
BROOKSVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34613-5414
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-596-6158
Provider Business Practice Location Address Fax Number:
352-596-6186
Provider Enumeration Date:
01/05/2009

Additional Information

Authorized Official

Authorized Official Last Name:
GANTI
Authorized Official First Name:
KRISHNA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
INITIAL OFFICER AND/OR DIRECTOR
Authorized Official Telephone Number:
352-596-6158

Provider Taxonomy Codes

  • Taxonomy code: 207Y00000X , with the licence number:  ME48997 , 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: 1952547507 . This is a "MEDICARE GROUP NPI" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 40001752 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 57664600 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 09499 . This is a "WELLCARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 02407 . This is a "BLUE CROSS FLORIDA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 1063413128 . This is a "MEDICARE INDIVIDUAL NPI" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 02407Y . This is a "MEDICARE INDIVIDUAL PTAN" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: BJ359 . This is a "MEDICARE GROUP PTAN" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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