1700874815 NPI number — MERCY GRANDAL ARNP

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 1700874815 NPI number — MERCY GRANDAL ARNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRANDAL
Provider First Name:
MERCY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ARNP
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:
1700874815
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/04/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
900 S PINE ISLAND RD
Provider Second Line Business Mailing Address:
SUITE 800
Provider Business Mailing Address City Name:
PLANTATION
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33324-3920
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-245-8050
Provider Business Mailing Address Fax Number:
305-245-8059

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3084 NE 41ST TER
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOMESTEAD
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33030-6619
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-245-8050
Provider Business Practice Location Address Fax Number:
305-245-8059
Provider Enumeration Date:
10/12/2005

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: 363LP0200X , with the licence number:  ARNP 9184215 , 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: 307126000 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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