Basic Information
| Provider Information | |||||||||
| NPI: | 1770721466 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHYSICIANS FOR A COMMUNITY UNITED FOR RESEARCH AND EDUCATION LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 19633 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322459633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043463338 | ||||||||
| FaxNumber: | 9043460815 | ||||||||
| Practice Location | |||||||||
| Address1: | 2003 CENTRE POINTE BLVD | ||||||||
| Address2: | |||||||||
| City: | TALLAHASSEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323084893 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508782273 | ||||||||
| FaxNumber: | 8506715900 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2009 | ||||||||
| LastUpdateDate: | 08/06/2009 | ||||||||
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| AuthorizedOfficialLastName: | PARYANI | ||||||||
| AuthorizedOfficialFirstName: | SHYAM | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9043463338 | ||||||||
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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 | 207RX0202X | FL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology | 2085R0001X | FL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 2085R0202X | FL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 207U00000X | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Nuclear Medicine |
ID Information
| ID | Type | State | Issuer | Description | 33021 | 01 | FL | BCBSFL | OTHER |