1104829399 NPI number — DR. JAY R PATTERSON MD

Table of content: DR. JAY R PATTERSON MD (NPI 1104829399)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104829399 NPI number — DR. JAY R PATTERSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PATTERSON
Provider First Name:
JAY
Provider Middle Name:
R
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
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:
1104829399
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/24/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
562 PARK ST
Provider Second Line Business Mailing Address:
STE 310
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32204-2962
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-633-2021
Provider Business Mailing Address Fax Number:
904-633-9793

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1801 BARRS ST
Provider Second Line Business Practice Location Address:
STE 500
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32204-4746
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-388-1820
Provider Business Practice Location Address Fax Number:
904-388-1827
Provider Enumeration Date:
05/23/2005

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: 207RC0001X , with the licence number:  ME62363 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RC0001X , with the licence number: 030852 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 212236 . This is a "AVMED" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 371127701 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4328516 . This is a "AETNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 67555 . This is a "BCBS" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 00518075A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00518075B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 15092 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 101048500 . 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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