1780738765 NPI number — DR. SAMUEL E PERKINS JR. MD

Table of content: DR. SAMUEL E PERKINS JR. MD (NPI 1780738765)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780738765 NPI number — DR. SAMUEL E PERKINS JR. MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PERKINS
Provider First Name:
SAMUEL
Provider Middle Name:
E
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1780738765
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/27/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11945 SAN JOSE BLVD.
Provider Second Line Business Mailing Address:
BLDG 300
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32223-1627
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-396-1725
Provider Business Mailing Address Fax Number:
904-399-1717

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1340 S 18TH ST
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
FERNANDINA BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32034-4733
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-277-3277
Provider Business Practice Location Address Fax Number:
904-277-3611
Provider Enumeration Date:
01/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  046209 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: ME 98802 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 310129 . This is a "AVMED" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 278432700 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7621418 . This is a "AETNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 78270 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 8997131 . This is a "CIGNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 000960242A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 022898700 . 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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