1114910924 NPI number — NEW HORIZONS: WOMEN'S MEDICAL GROUP, P.A.

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 1114910924 NPI number — NEW HORIZONS: WOMEN'S MEDICAL GROUP, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEW HORIZONS: WOMEN'S MEDICAL GROUP, P.A.
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:
Provider Other Organization Name Type Code:
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:
1114910924
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3901 UNIVERSITY BLVD S
Provider Second Line Business Mailing Address:
SUITE 215
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32216-4377
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-296-3200
Provider Business Mailing Address Fax Number:
904-296-0069

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
802 PORT WINE LN
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:
32225-5230
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-220-3725
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/26/2005

Additional Information

Authorized Official

Authorized Official Last Name:
WILLIS
Authorized Official First Name:
DEBBIE
Authorized Official Middle Name:
Authorized Official Title or Position:
BUSINESS ADMINISTRATOR
Authorized Official Telephone Number:
904-281-0780

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 45591 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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