Provider Demographics
NPI:1124274493
Name:MARK A EBERBACH MD PA
Entity type:Organization
Organization Name:MARK A EBERBACH MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:EBERBACH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-868-4490
Mailing Address - Street 1:14012 US HIGHWAY 19
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:FL
Mailing Address - Zip Code:34667-1165
Mailing Address - Country:US
Mailing Address - Phone:727-868-4490
Mailing Address - Fax:727-869-7085
Practice Address - Street 1:14012 US HIGHWAY 19
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:FL
Practice Address - Zip Code:34667-1165
Practice Address - Country:US
Practice Address - Phone:727-868-4490
Practice Address - Fax:727-869-7085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-18
Last Update Date:2009-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0048142261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL07923OtherBLUE CROSS BLUE SHIELD
FLE31250OtherUPIN
FLK5399OtherMEDICARE PROVIDER NUMBER