Provider Demographics
NPI:1083715502
Name:PODIATRY ASSOCIATES OF FLORIDA INC
Entity Type:Organization
Organization Name:PODIATRY ASSOCIATES OF FLORIDA INC
Other - Org Name:PODIATRY ASSOCIATES OF NORTHEAST FLORIDA INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CORPORATE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JEANNIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:BASKIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-251-5053
Mailing Address - Street 1:5911 TIMUQUANA RD UNIT 300
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32210-7897
Mailing Address - Country:US
Mailing Address - Phone:904-251-5053
Mailing Address - Fax:904-224-2002
Practice Address - Street 1:2140 KINGSLEY AVE
Practice Address - Street 2:STE 12
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-5180
Practice Address - Country:US
Practice Address - Phone:904-272-7070
Practice Address - Fax:904-272-3668
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
480030919OtherRAILROAD MEDICARE
FL390364800Medicaid
FLCI4974OtherMEDICARE
P00442507OtherRAILROAD MEDICARE
87629OtherBLUE CROSS BLUE SHIELD
480026736OtherRAILROAD MEDICARE
65490OtherBLUE CROSS BLUE SHIELD
87629OtherBLUE CROSS BLUE SHIELD
21698KMedicare PIN