Provider Demographics
NPI:1023039161
Name:PSYCHIATRIC ASSOCIATES, PA
Entity Type:Organization
Organization Name:PSYCHIATRIC ASSOCIATES, PA
Other - Org Name:GENOVA AND ASSOCIATES
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:LIONEL
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-264-6977
Mailing Address - Street 1:1543 KINGSLEY AVE
Mailing Address - Street 2:BLDG 14
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-4535
Mailing Address - Country:US
Mailing Address - Phone:904-264-6977
Mailing Address - Fax:904-269-0870
Practice Address - Street 1:1543 KINGSLEY AVE
Practice Address - Street 2:BLDG 14
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4535
Practice Address - Country:US
Practice Address - Phone:904-264-6977
Practice Address - Fax:904-269-0870
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL45114Medicare ID - Type UnspecifiedGROUP NUMBER