1962552752 NPI number — PSYCHIATRIC ASSOCIATES OF LAKE CITY PA

Table of content: (NPI 1962552752)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962552752 NPI number — PSYCHIATRIC ASSOCIATES OF LAKE CITY PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PSYCHIATRIC ASSOCIATES OF LAKE CITY 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:
6
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:
1962552752
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/14/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
165 SW VISION GLENN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE CITY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32025-1111
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-755-1800
Provider Business Mailing Address Fax Number:
386-758-8770

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
165 SW VISION GLENN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE CITY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32025-1111
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-755-1800
Provider Business Practice Location Address Fax Number:
386-758-8770
Provider Enumeration Date:
01/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MHATRE
Authorized Official First Name:
SHILPA
Authorized Official Middle Name:
U.
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
386-755-1800

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  ME0027561 , 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: 264574342 . This is a "CHAMPUS TRICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: ME 0027561 . This is a "FLORIDA LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 01251 . This is a "BC BS OF FL" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 037553500 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 083097 . This is a "MHN" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 406263894 . This is a "RAIL ROAD MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com