Basic Information
| Provider Information | |||||||||
| NPI: | 1720619422 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PEDIATRIC ASSOCIATES OF NORTHEAST FLORIDA, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | JACKSONVILLE PEDIATRIC ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900 S PINE ISLAND RD STE 800 | ||||||||
| Address2: | |||||||||
| City: | PLANTATION | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333243923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9549676400 | ||||||||
| FaxNumber: | 9549657339 | ||||||||
| Practice Location | |||||||||
| Address1: | 155 BARTRAM MARKET DR STE 120 | ||||||||
| Address2: | |||||||||
| City: | ST JOHNS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322594582 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9046502193 | ||||||||
| FaxNumber: | 9042016350 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2020 | ||||||||
| LastUpdateDate: | 05/19/2021 | ||||||||
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| AuthorizedOfficialLastName: | CORSIATTO | ||||||||
| AuthorizedOfficialFirstName: | PATRICIA | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9549657331 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 05/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 011962603 | 05 | FL | MEDICAID |