Basic Information
| Provider Information | |||||||||
| NPI: | 1316916265 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REIDY | ||||||||
| FirstName: | COURTNEY | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LUCADO | ||||||||
| OtherFirstName: | COURTNEY | ||||||||
| OtherMiddleName: | S | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1200 RIVERPLACE BLVD | ||||||||
| Address2: | SUITE 620 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322079046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043966620 | ||||||||
| FaxNumber: | 9043966528 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 RIVERPLACE BLVD | ||||||||
| Address2: | SUITE 620 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322079046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043966620 | ||||||||
| FaxNumber: | 9043966528 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2006 | ||||||||
| LastUpdateDate: | 06/11/2013 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | ME97574 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 01012333389 | VA | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 574322629A | 05 | GA | MEDICAID | 277376700 | 05 | FL | MEDICAID | 91847 | 01 | FL | BCBS | OTHER |