Basic Information
| Provider Information | |||||||||
| NPI: | 1043346745 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JACKSONVILLE PEDIATRICS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2606 PARK ST | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322044520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043884646 | ||||||||
| FaxNumber: | 9043889071 | ||||||||
| Practice Location | |||||||||
| Address1: | 2606 PARK ST | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322044520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043884646 | ||||||||
| FaxNumber: | 9043889071 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2007 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | THORNTON | ||||||||
| AuthorizedOfficialFirstName: | RANDOLPH | ||||||||
| AuthorizedOfficialMiddleName: | EDENS | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 9043894140 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080A0000X | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine |
No ID Information.