Basic Information
| Provider Information | |||||||||
| NPI: | 1659337756 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OBGYN ASSOCIATES OF ST AUGUSTINE PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 HEALTH PARK BLVD | ||||||||
| Address2: | STE 3002 | ||||||||
| City: | ST AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32086 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048191500 | ||||||||
| FaxNumber: | 9048101023 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 HEALTH PARK BLVD | ||||||||
| Address2: | STE 3002 | ||||||||
| City: | ST AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32086 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048191500 | ||||||||
| FaxNumber: | 9048101023 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2006 | ||||||||
| LastUpdateDate: | 12/03/2007 | ||||||||
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| AuthorizedOfficialLastName: | YARIAN | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9048191500 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 0066572 | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 264245000 | 05 | FL | MEDICAID |