Provider Demographics
NPI:1003419763
Name:MAINLAND PHYSICIANS GROUP LLC
Entity Type:Organization
Organization Name:MAINLAND PHYSICIANS GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF NETWORK MANAGMENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN PAUL
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:SHADDOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-341-6322
Mailing Address - Street 1:100 ARRICOLA AVE
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080-4515
Mailing Address - Country:US
Mailing Address - Phone:904-825-4368
Mailing Address - Fax:904-825-9107
Practice Address - Street 1:100 ARRICOLA AVE
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32080-4515
Practice Address - Country:US
Practice Address - Phone:904-825-4368
Practice Address - Fax:904-825-9107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-17
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Single Specialty