Basic Information
| Provider Information | |||||||||
| NPI: | 1457587891 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PERRY JC MD PA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | THE COLE CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3123 | ||||||||
| Address2: | |||||||||
| City: | ST AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320853123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048244990 | ||||||||
| FaxNumber: | 9048242226 | ||||||||
| Practice Location | |||||||||
| Address1: | 7999 PHILIPS HWY | ||||||||
| Address2: | STE 302 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322564443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9047330099 | ||||||||
| FaxNumber: | 9047330070 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2009 | ||||||||
| LastUpdateDate: | 05/27/2011 | ||||||||
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| AuthorizedOfficialLastName: | COLE | ||||||||
| AuthorizedOfficialFirstName: | PERRY | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9047330099 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0014X | ME83999 | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0014P | 01 | FL | BCBS | OTHER | 002608400 | 05 | FL | MEDICAID | 614424600 | 01 | FL | OWCP - FECA | OTHER | 7511404 | 01 | FL | AETNA | OTHER |