Basic Information
| Provider Information | |||||||||
| NPI: | 1306962865 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MIDNIGHT PASS CHIROPRACTIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3900 CLARK RD | ||||||||
| Address2: | H-1 | ||||||||
| City: | SARASOTA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342332301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9419261600 | ||||||||
| FaxNumber: | 9419261166 | ||||||||
| Practice Location | |||||||||
| Address1: | 3900 CLARK RD | ||||||||
| Address2: | H-1 | ||||||||
| City: | SARASOTA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342332301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9419261600 | ||||||||
| FaxNumber: | 9419261166 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2007 | ||||||||
| LastUpdateDate: | 01/23/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BERMAN | ||||||||
| AuthorizedOfficialFirstName: | JONATHAN | ||||||||
| AuthorizedOfficialMiddleName: | ALAN | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9419261600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DC | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111NS0005X | Y | 193400000X SINGLE SPECIALTY GROUP | Chiropractic Providers | Chiropractor | Sports Physician |
ID Information
| ID | Type | State | Issuer | Description | CH886 | 01 | FL | STATE LICENSE | OTHER |