1962778308 NPI number — DR. LEIGH JOANNE WARD RUTH MD

Table of content: DR. LEIGH JOANNE WARD RUTH MD (NPI 1962778308)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962778308 NPI number — DR. LEIGH JOANNE WARD RUTH MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUTH
Provider First Name:
LEIGH
Provider Middle Name:
JOANNE WARD
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RUTH
Provider Other First Name:
LEIGH
Provider Other Middle Name:
JOANNE
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1962778308
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/31/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 917770
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORLANDO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32891-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-974-2201
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3515 E FLETCHER AVE # MDC14
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TAMPA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33613-4706
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-974-4657
Provider Business Practice Location Address Fax Number:
813-974-3236
Provider Enumeration Date:
03/29/2012

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: 2084P0804X , with the licence number:  ME132274 , 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: 021751200 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0R6TM . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 021751200 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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