=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679097307
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EMBRY-RIDDLE AERONAUTICAL UNIVERSITY, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/03/2017
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 600 S CLYDE MORRIS BLVD
-----------------------------------------------------
City | DAYTONA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32114-3966
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-226-7912
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 600 S CLYDE MORRIS BLVD
-----------------------------------------------------
City | DAYTONA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32114-3966
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-226-7912
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MARIANNE BASKIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 386-226-7912
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------