Basic Information
| Provider Information | |||||||||
| NPI: | 1578514386 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTERNAL MEDICINE ASSOCIATES OF NORTHEAST FLORIDA PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1555 KINGSLEY AVE | ||||||||
| Address2: | SUITE 604 | ||||||||
| City: | ORANGE PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320734560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9045410670 | ||||||||
| FaxNumber: | 9045410680 | ||||||||
| Practice Location | |||||||||
| Address1: | 1555 KINGSLEY AVE | ||||||||
| Address2: | SUITE 604 | ||||||||
| City: | ORANGE PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320734560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9045410670 | ||||||||
| FaxNumber: | 9045410680 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2006 | ||||||||
| LastUpdateDate: | 02/21/2008 | ||||||||
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| AuthorizedOfficialLastName: | MCLEAN | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
| AuthorizedOfficialMiddleName: | LYN | ||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9045410702 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.