Basic Information
| Provider Information | |||||||||
| NPI: | 1770739104 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHYSICIANS FOR A COMMUNITY UNITED FOR RESEARCH AND EDUCATION LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3599 UNIVERSITY BLVD S STE 1000 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322164280 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043463338 | ||||||||
| FaxNumber: | 9043460815 | ||||||||
| Practice Location | |||||||||
| Address1: | 795 SW STATE ROAD 47 | ||||||||
| Address2: | |||||||||
| City: | LAKE CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320250453 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3867587822 | ||||||||
| FaxNumber: | 3867582224 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2008 | ||||||||
| LastUpdateDate: | 07/14/2009 | ||||||||
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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: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207U00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Nuclear Medicine | 2085R0001X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | DO8891 | 01 | FL | RR MEDICARE | OTHER | 33201 | 01 | FL | BCBS OF FL | OTHER |