1952556821 NPI number — RAUL CARRILLO MD PA

Table of content: MS. CYNTHIA CATHERINE BRAUER FAMILY PEER ADVOCATE (NPI 1104575604)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952556821 NPI number — RAUL CARRILLO MD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RAUL CARRILLO 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:
1952556821
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/29/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
929 N. HWY 27/441
Provider Second Line Business Mailing Address:
SUITE 302
Provider Business Mailing Address City Name:
LADY LAKE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32159-8999
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-391-1115
Provider Business Mailing Address Fax Number:
352-391-5206

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
929. N. HWY 27/441
Provider Second Line Business Practice Location Address:
SUITE 302
Provider Business Practice Location Address City Name:
LADY LAKE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32159
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-391-1115
Provider Business Practice Location Address Fax Number:
352-391-5206
Provider Enumeration Date:
11/19/2008

Additional Information

Authorized Official

Authorized Official Last Name:
CARRILLO
Authorized Official First Name:
RAUL
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
352-391-1115

Provider Taxonomy Codes

  • Taxonomy code: 207RP1001X , with the licence number:  ME87534 , 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: 267028300 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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