Basic Information
Provider Information | |||||||||
NPI: | 1477174456 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MANATEE URGENT CARE LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 367 S. GULPH ROAD | ||||||||
Address2: | ATT: IPM CREDENTIALING | ||||||||
City: | KING OF PRUSSIA | ||||||||
State: | PA | ||||||||
PostalCode: | 194063121 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6103824943 | ||||||||
FaxNumber: | 6108783965 | ||||||||
Practice Location | |||||||||
Address1: | 4647 MANATEE AVE W | ||||||||
Address2: |   | ||||||||
City: | BRADENTON | ||||||||
State: | FL | ||||||||
PostalCode: | 342093816 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9417455999 | ||||||||
FaxNumber: | 9417453555 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/01/2020 | ||||||||
LastUpdateDate: | 05/01/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | EVANS | ||||||||
AuthorizedOfficialFirstName: | TODD | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VP | ||||||||
AuthorizedOfficialTelephone: | 6103824943 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/01/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
No ID Information.