1083715502 NPI number — PODIATRY ASSOCIATES OF FLORIDA INC

Table of content: (NPI 1083715502)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083715502 NPI number — PODIATRY ASSOCIATES OF FLORIDA INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PODIATRY ASSOCIATES OF FLORIDA INC
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:
6
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:
1083715502
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/05/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5911 TIMUQUANA RD UNIT 300
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:
32210-7897
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-251-5053
Provider Business Mailing Address Fax Number:
904-224-2002

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2140 KINGSLEY AVE
Provider Second Line Business Practice Location Address:
STE 12
Provider Business Practice Location Address City Name:
ORANGE PARK
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32073-5180
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-272-7070
Provider Business Practice Location Address Fax Number:
904-272-3668
Provider Enumeration Date:
09/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BASKIN
Authorized Official First Name:
JEANNIE
Authorized Official Middle Name:
M
Authorized Official Title or Position:
CORPORATE ADMINISTRATOR
Authorized Official Telephone Number:
904-251-5053

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213ES0103X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 480030919 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 390364800 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: CI4974 . This is a "MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: P00442507 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 87629 . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 480026736 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 65490 . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".




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