Basic Information
| Provider Information | |||||||||
| NPI: | 1093325987 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FLAGLER PROFESSIONAL HEALTH CARE SERVICES INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3266 | ||||||||
| Address2: | |||||||||
| City: | ST AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320853266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048194602 | ||||||||
| FaxNumber: | 9048194426 | ||||||||
| Practice Location | |||||||||
| Address1: | 351 TOWN PLAZA AVENUE | ||||||||
| Address2: | 101 | ||||||||
| City: | PONTE VEDRA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32081 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048194602 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2020 | ||||||||
| LastUpdateDate: | 08/05/2020 | ||||||||
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| AuthorizedOfficialLastName: | FRANKS | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | WELLS | ||||||||
| AuthorizedOfficialTitleorPosition: | DELEGATED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 9048194065 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FLAGLER PROFESSIONAL HEALTH CARE SERVICES INC. | ||||||||
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| NPICertificationDate: | 08/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085U0001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound | 261QM1200X | N | Ambulatory Health Care Facilities | Clinic/Center | Magnetic Resonance Imaging (MRI) | 261QR0206X | N | Ambulatory Health Care Facilities | Clinic/Center | Radiology, Mammography | 261QR0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
No ID Information.