Provider Demographics
NPI:1043346745
Name:JACKSONVILLE PEDIATRICS
Entity Type:Organization
Organization Name:JACKSONVILLE PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDOLPH
Authorized Official - Middle Name:EDENS
Authorized Official - Last Name:THORNTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-389-4140
Mailing Address - Street 1:2606 PARK ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-4520
Mailing Address - Country:US
Mailing Address - Phone:904-388-4646
Mailing Address - Fax:904-388-9071
Practice Address - Street 1:2606 PARK ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4520
Practice Address - Country:US
Practice Address - Phone:904-388-4646
Practice Address - Fax:904-388-9071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty