Basic Information
| Provider Information | |||||||||
| NPI: | 1790845337 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTH FLORIDA REGIONAL EYECARE, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 VILLAGE SQUARE BLVD | ||||||||
| Address2: | SUITE 3-165 | ||||||||
| City: | TALLAHASSEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323121250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8502223937 | ||||||||
| FaxNumber: | 8508770206 | ||||||||
| Practice Location | |||||||||
| Address1: | 1905 CAPITAL CIR NE | ||||||||
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| City: | TALLAHASSEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323084421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8502223937 | ||||||||
| FaxNumber: | 8508939987 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2006 | ||||||||
| LastUpdateDate: | 01/09/2017 | ||||||||
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| AuthorizedOfficialLastName: | STEPHENS | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8508934005 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | O.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 24269 | 01 | FL | BCBS GROUP NUMBER | OTHER | 620174100 | 05 | FL | MEDICAID |