Provider Demographics
NPI:1114106911
Name:ORANGE PARK HOSPITALISTS LLC
Entity Type:Organization
Organization Name:ORANGE PARK HOSPITALISTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:JAIME
Authorized Official - Middle Name:M
Authorized Official - Last Name:GIBBS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-962-4271
Mailing Address - Street 1:1893 KINGSLEY AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-4491
Mailing Address - Country:US
Mailing Address - Phone:904-276-2044
Mailing Address - Fax:904-276-2106
Practice Address - Street 1:1800 BARRS ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4704
Practice Address - Country:US
Practice Address - Phone:904-276-2044
Practice Address - Fax:904-276-2106
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-29
Last Update Date:2008-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL34877Medicare PIN