Basic Information
Provider Information | |||||||||
NPI: | 1760093702 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NORTH FLORIDA PRIMARY CARE PLLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 221 SW STONEGATE TER STE 101 | ||||||||
Address2: |   | ||||||||
City: | LAKE CITY | ||||||||
State: | FL | ||||||||
PostalCode: | 320243463 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3862927744 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 221 SW STONEGATE TER STE 101 | ||||||||
Address2: |   | ||||||||
City: | LAKE CITY | ||||||||
State: | FL | ||||||||
PostalCode: | 320243463 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3862927744 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/13/2020 | ||||||||
LastUpdateDate: | 12/09/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | UKAEGBU | ||||||||
AuthorizedOfficialFirstName: | MICHAEL | ||||||||
AuthorizedOfficialMiddleName: | C | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 3866974973 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: | SR. | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: | 10/14/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 010767000 | 05 | FL |   | MEDICAID |