Provider Demographics
NPI:1013391275
Name:BEACHES EAR, NOSE AND THROAT, PA
Entity Type:Organization
Organization Name:BEACHES EAR, NOSE AND THROAT, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:E
Authorized Official - Last Name:BRINK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-247-4070
Mailing Address - Street 1:PO BOX 3217
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32004-3217
Mailing Address - Country:US
Mailing Address - Phone:904-247-4070
Mailing Address - Fax:904-247-4131
Practice Address - Street 1:3200 3RD ST S
Practice Address - Street 2:SUITE 101
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-6096
Practice Address - Country:US
Practice Address - Phone:904-247-4070
Practice Address - Fax:904-247-4131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-16
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAY1951231HA2400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231HA2400XSpeech, Language and Hearing Service ProvidersAudiologistAssistive Technology PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL269691601Medicaid
FL269691601Medicaid
FLG06095Medicare UPIN