1578664074 NPI number — PODIATRY ASSOCIATES OF FLORIDA INC

Table of content: (NPI 1578664074)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578664074 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:
1578664074
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/07/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2140 KINGSLEY AVE STE 12
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORANGE PARK
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32073-5129
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-224-2001
Provider Business Mailing Address Fax Number:
904-224-2002

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1361 13TH AVE S
Provider Second Line Business Practice Location Address:
STE 120
Provider Business Practice Location Address City Name:
JACKSONVILLE BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32250-3233
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-224-2001
Provider Business Practice Location Address Fax Number:
904-224-2002
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: "Y" .

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

  • Identifier: DC3124 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 041050100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 87368 . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 65767 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 480028094 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 65207 . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00249337 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00603529 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: CI4974 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 110360000 . 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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