Basic Information
Provider Information | |||||||||
NPI: | 1215930334 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SKOTNICKI | ||||||||
FirstName: | ROBERT | ||||||||
MiddleName: | ALAN | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1020 LAKE SUMTER LNDG | ||||||||
Address2: |   | ||||||||
City: | THE VILLAGES | ||||||||
State: | FL | ||||||||
PostalCode: | 321622699 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3526748820 | ||||||||
FaxNumber: | 3526748919 | ||||||||
Practice Location | |||||||||
Address1: | 1400 N US HIGHWAY 441 | ||||||||
Address2: | SUITE 810 | ||||||||
City: | THE VILLAGES | ||||||||
State: | FL | ||||||||
PostalCode: | 321598975 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3526748700 | ||||||||
FaxNumber: | 3526748714 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/23/2005 | ||||||||
LastUpdateDate: | 03/20/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | OS004652L | PA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | OS13035 | FL | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
ID | Type | State | Issuer | Description | 0011376640001 | 05 | PA |   | MEDICAID | 060012838 | 01 |   | RAILROAD MEDICARE | OTHER |