1962074070 NPI number — FWC UROGYNECOLOGY, LLC

Table of content: (NPI 1962074070)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962074070 NPI number — FWC UROGYNECOLOGY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FWC UROGYNECOLOGY, LLC
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:
1962074070
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/07/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5556
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELFAST
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04915-5500
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-300-2410
Provider Business Mailing Address Fax Number:
561-235-7292

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6885 BELFORT OAKS PL STE 110
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32216-6281
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-652-0373
Provider Business Practice Location Address Fax Number:
904-652-0378
Provider Enumeration Date:
07/16/2021

Additional Information

Authorized Official

Authorized Official Last Name:
HERNANDEZ
Authorized Official First Name:
ERICA
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
561-300-2410

Provider Taxonomy Codes

  • Taxonomy code: 2088F0040X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 004531438 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com