1598033805 NPI number — PHYSICIANS GROUP SERVICES PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598033805 NPI number — PHYSICIANS GROUP SERVICES PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHYSICIANS GROUP SERVICES PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
KIDNEY CLINICS OF JACKSONVILLE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1598033805
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
705 WELLS RD STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORANGE PARK
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32073-2982
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-282-6331
Provider Business Mailing Address Fax Number:
904-619-1080

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14540 OLD SAINT AUGUSTINE RD STE 2397
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32258-7418
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-296-0670
Provider Business Practice Location Address Fax Number:
904-296-0698
Provider Enumeration Date:
12/01/2011

Additional Information

Authorized Official

Authorized Official Last Name:
GLENN
Authorized Official First Name:
CHRISTOPHER
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
904-282-6331

Provider Taxonomy Codes

  • Taxonomy code: 207RN0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 259123500 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 259123520 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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