Basic Information
| Provider Information | |||||||||
| NPI: | 1801999545 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PULMONARY ASSOCIATES OF ST | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 860305 | ||||||||
| Address2: | |||||||||
| City: | ST AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320860305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048244990 | ||||||||
| FaxNumber: | 9048242226 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 HEALTH PARK BLVD | ||||||||
| Address2: | SUITE 4000 | ||||||||
| City: | ST AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320863707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048248933 | ||||||||
| FaxNumber: | 9048248666 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2006 | ||||||||
| LastUpdateDate: | 03/03/2009 | ||||||||
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| AuthorizedOfficialLastName: | HUSAIN | ||||||||
| AuthorizedOfficialFirstName: | KISHWAR | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9048248933 | ||||||||
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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 | 207RP1001X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 272728500 | 05 | FL | MEDICAID | DD4747 | 01 | FL | RAILROAD MEDICARE | OTHER |