=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962672337
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KAPIL PURI MD P A
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/02/2008
-----------------------------------------------------
Last Update Date | 08/21/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1001 COLLEGE BLVD W STE H
-----------------------------------------------------
City | NICEVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32578-1099
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-279-4600
-----------------------------------------------------
Fax | 850-279-4566
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 524
-----------------------------------------------------
City | NICEVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32588-0524
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-279-4500
-----------------------------------------------------
Fax | 850-279-4566
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. KAPIL PURI
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 850-279-4600
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208800000X
-----------------------------------------------------
Taxonomy Name | Urology Physician
-----------------------------------------------------
License Number | ME91106
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------