Provider Demographics
NPI:1063850295
Name:FLORIDA CLINICAL PRACTICE ASSOCIATION INC
Entity Type:Organization
Organization Name:FLORIDA CLINICAL PRACTICE ASSOCIATION INC
Other - Org Name:UF HEALTH PEDIATRICS - MAGNOLIA PARKE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:
Authorized Official - Last Name:SIBISKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-265-8017
Mailing Address - Street 1:PO BOX 13833
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19101-3833
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4740 NW 39TH PL
Practice Address - Street 2:STE B
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32606-7226
Practice Address - Country:US
Practice Address - Phone:352-594-7337
Practice Address - Fax:352-265-5343
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-10
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL053386643Medicaid