1053981142 NPI number — AVECINA MEDICAL PA

Table of content: (NPI 1053981142)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053981142 NPI number — AVECINA MEDICAL PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AVECINA MEDICAL 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:
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:
1053981142
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/29/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4815 SWEETGRASS PL STE 201
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32224-0131
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4160 SOUTHSIDE BLVD
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:
32216-8500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-900-1717
Provider Business Practice Location Address Fax Number:
904-367-2143
Provider Enumeration Date:
06/30/2021

Additional Information

Authorized Official

Authorized Official Last Name:
MORETTI KIGHT
Authorized Official First Name:
AMANDA
Authorized Official Middle Name:
Authorized Official Title or Position:
BILLING MANAGER
Authorized Official Telephone Number:
904-723-4707

Provider Taxonomy Codes

  • Taxonomy code: 261QU0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 006670005 . 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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