Provider Demographics
NPI:1114323631
Name:FARGHALY MEDICAL, PLLC
Entity Type:Organization
Organization Name:FARGHALY MEDICAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:BURNSIDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-826-7932
Mailing Address - Street 1:100 WHETSTONE PL
Mailing Address - Street 2:SUITE 208
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-5774
Mailing Address - Country:US
Mailing Address - Phone:904-826-7932
Mailing Address - Fax:904-819-6700
Practice Address - Street 1:100 WHETSTONE PL
Practice Address - Street 2:SUITE 208
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5774
Practice Address - Country:US
Practice Address - Phone:904-826-7932
Practice Address - Fax:904-819-6700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-11
Last Update Date:2014-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME97900207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPENDINGOtherPENDING