=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225936586
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEDIVIGIL SENIOR MEDICAL SERVICES FL PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/27/2026
-----------------------------------------------------
Last Update Date | 10/27/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 N LAURA ST
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32202-3513
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-201-1252
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 407 WILLOUGHBY AVE
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11205-4590
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-201-1252
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. AZLAN TARIQ
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 212-201-1252
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225400000X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------