NPIMap

Organization Active NPI

Medical Pavilion Clinc

  • Preferred Provider Organization
  • Port Charlotte, FL
National Provider Identifier
1063671683
Registry record updated Jun 9, 2008
On this page

Key facts

NPPES NPI Registry
Primary specialty
Preferred Provider OrganizationTaxonomy code 305R00000X
License
ME0044391 Issued in FL
Legal business name
MEDICAL PAVILION CLINC
Practice address
2525 Harbor Blvd
Suite 102
Port Charlotte, FL 33952-5317
Phone
(941) 629-9190
Fax
(941) 625-2751
NPI assigned
Jun 9, 2008
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 9, 2008

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
David S BallestasNPI 1609969419
Title
Doctor - Owner
Phone
(941) 629-9190

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Preferred Provider Organization 305R00000X ME0044391 FL Primary

Addresses

Primary practice location

2525 Harbor Blvd
Suite 102
Port Charlotte, FL 33952-5317

Mailing address

2525 Harbor Blvd
Suite 102
Port Charlotte, FL 33952-5317
Phone (941) 629-9190

Other identifiers 1

IdentifierTypeStateIssuer
0608916500MedicaidFL

National Provider Directory

National Provider Directory

Locations

2525 Harbor Blvd
Ste 102
Pt Charlotte, FL 33952
Phone (941) 629-7593

Practitioners & affiliated clinicians

Practitioners 10

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1212969600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1212969600000",
    "number": "1063671683",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2525 HARBOR BLVD",
            "address_2": "SUITE 102",
            "city": "PORT CHARLOTTE",
            "state": "FL",
            "postal_code": "339525317",
            "telephone_number": "941-629-9190",
            "fax_number": "941-625-2751"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2525 HARBOR BLVD",
            "address_2": "SUITE 102",
            "city": "PORT CHARLOTTE",
            "state": "FL",
            "postal_code": "339525317",
            "telephone_number": "941-629-9190",
            "fax_number": "941-625-2751"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MEDICAL PAVILION CLINC",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-06-09",
        "last_updated": "2008-06-09",
        "status": "A",
        "authorized_official_last_name": "BALLESTAS",
        "authorized_official_first_name": "DAVID",
        "authorized_official_middle_name": "S",
        "authorized_official_title_or_position": "DOCTOR - OWNER",
        "authorized_official_telephone_number": "941-629-9190"
    },
    "taxonomies": [
        {
            "code": "305R00000X",
            "taxonomy_group": "",
            "desc": "Preferred Provider Organization",
            "state": "FL",
            "license": "ME0044391",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0608916500",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Port Charlotte, FL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 9, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.