Basic Information
| Provider Information | |||||||||
| NPI: | 1487769576 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE EHS MEDICAL PRACTICE PA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | SARKIS FAMILY PSYCHIATRY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 529 NE 60TH ST | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326072008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523315100 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 529 NE 60TH ST | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326072008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523315100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2006 | ||||||||
| LastUpdateDate: | 04/16/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HOVER | ||||||||
| AuthorizedOfficialFirstName: | DONNA | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | NURSE | ||||||||
| AuthorizedOfficialTelephone: | 3523315100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LPN | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | ME 161274 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 34968 | 01 | FL | BLUE CROSS / BLUE SHIELD | OTHER |