1528194131 NPI number — DR. SHELANDA CHARISE HAYES MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528194131 NPI number — DR. SHELANDA CHARISE HAYES MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HAYES
Provider First Name:
SHELANDA
Provider Middle Name:
CHARISE
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:
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:
1528194131
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/20/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13229 TRADITION DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DADE CITY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33525-6219
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-799-9700
Provider Business Mailing Address Fax Number:
708-799-9701

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19740 GOVERNORS HWY
Provider Second Line Business Practice Location Address:
STE 116
Provider Business Practice Location Address City Name:
FLOSSMOOR
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60422-2085
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-799-9700
Provider Business Practice Location Address Fax Number:
708-799-9701
Provider Enumeration Date:
02/26/2007

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: 174H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 036-108398 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 104146600 . 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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