1891012365 NPI number — JAX OB-GYN PA

Table of content: (NPI 1891012365)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891012365 NPI number — JAX OB-GYN PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JAX OB-GYN 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:
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:
1891012365
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/30/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4123 UNIVERSITY BLVD S.
Provider Second Line Business Mailing Address:
SUITE D
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32216
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-737-1920
Provider Business Mailing Address Fax Number:
904-737-8932

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4123 UNIVERSITY BLVD S.
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32216
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-737-1920
Provider Business Practice Location Address Fax Number:
904-737-8932
Provider Enumeration Date:
04/23/2010

Additional Information

Authorized Official

Authorized Official Last Name:
KHOSRAVI
Authorized Official First Name:
HORMOZ
Authorized Official Middle Name:
Authorized Official Title or Position:
DR./OWNER
Authorized Official Telephone Number:
904-737-1920

Provider Taxonomy Codes

  • Taxonomy code: 207VG0400X , with the licence number:  ME32812 , 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: 037158100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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