Basic Information
Provider Information | |||||||||
NPI: | 1194793471 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LIN | ||||||||
FirstName: | JACK | ||||||||
MiddleName: | CHI | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1 TAMPA GENERAL CIR | ||||||||
Address2: | SUITE A327 | ||||||||
City: | TAMPA | ||||||||
State: | FL | ||||||||
PostalCode: | 336063571 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8138444434 | ||||||||
FaxNumber: | 8138444972 | ||||||||
Practice Location | |||||||||
Address1: | 400 N ASHLEY DR | ||||||||
Address2: | SUITE 1625 | ||||||||
City: | TAMPA | ||||||||
State: | FL | ||||||||
PostalCode: | 336024300 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8138444434 | ||||||||
FaxNumber: | 8138444972 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/10/2006 | ||||||||
LastUpdateDate: | 07/13/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 218742 | MA | N |   | Allopathic & Osteopathic Physicians | Anesthesiology |   | 207L00000X | 0101242067 | VA | N |   | Allopathic & Osteopathic Physicians | Anesthesiology |   | 207L00000X | ME124687 | FL | Y |   | Allopathic & Osteopathic Physicians | Anesthesiology |   |
ID Information
ID | Type | State | Issuer | Description | 1194793471 | 05 | VA |   | MEDICAID | 022709F89 | 01 | DC | MEDICARE | OTHER |