1477501153 NPI number — PENSACOLA NEPHROLOGY PA

Table of content: (NPI 1477501153)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477501153 NPI number — PENSACOLA NEPHROLOGY PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PENSACOLA NEPHROLOGY 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:
1477501153
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/14/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 11037
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PENSACOLA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32524-1037
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-444-7000
Provider Business Mailing Address Fax Number:
850-444-8144

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4304 LANCASTER DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NICEVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32578-4563
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-862-2385
Provider Business Practice Location Address Fax Number:
850-862-0482
Provider Enumeration Date:
05/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BREELAND
Authorized Official First Name:
PATRICIA
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
850-444-4700

Provider Taxonomy Codes

  • Taxonomy code: 207RN0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 256870500 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 256870502 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 256870501 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 256870507 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 256870504 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 256870503 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 256870505 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 256870506 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 256870508 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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