Basic Information
Provider Information | |||||||||
NPI: | 1548600869 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PORT ORANGE GYNECOLOGY LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PORT ORANGE GYNECOLOGY LLC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 12051 | ||||||||
Address2: |   | ||||||||
City: | BELFAST | ||||||||
State: | ME | ||||||||
PostalCode: | 049154011 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3864926929 | ||||||||
FaxNumber: | 3864926930 | ||||||||
Practice Location | |||||||||
Address1: | 900 N SWALLOWTAIL DR | ||||||||
Address2: | ST 102B | ||||||||
City: | PORT ORANGE | ||||||||
State: | FL | ||||||||
PostalCode: | 321296102 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3864926929 | ||||||||
FaxNumber: | 3864926930 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/01/2013 | ||||||||
LastUpdateDate: | 10/09/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FOUST | ||||||||
AuthorizedOfficialFirstName: | PAULA | ||||||||
AuthorizedOfficialMiddleName: | M. | ||||||||
AuthorizedOfficialTitleorPosition: | M.D. OWNER | ||||||||
AuthorizedOfficialTelephone: | 3864926929 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VG0400X | ME97528 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology |
ID Information
ID | Type | State | Issuer | Description | 277730400 | 05 | FL |   | MEDICAID |