Provider Demographics
NPI:1235232273
Name:NORTHEAST FLORIDA PRIMARY CARE CLINIC
Entity Type:Organization
Organization Name:NORTHEAST FLORIDA PRIMARY CARE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:PULWERS
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:904-215-9266
Mailing Address - Street 1:1835 EAST-WEST PARKWAY
Mailing Address - Street 2:SUITE 11
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32003
Mailing Address - Country:US
Mailing Address - Phone:904-215-9266
Mailing Address - Fax:904-264-4651
Practice Address - Street 1:1835 EAST-WEST PARKWAY
Practice Address - Street 2:SUITE 11
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32003
Practice Address - Country:US
Practice Address - Phone:904-215-9266
Practice Address - Fax:904-264-4651
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0076341207Q00000X
FLME0068123207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
45491Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER