Provider Demographics
NPI:1407286727
Name:MJA HEALTHCARE OF FLORIDA, PC
Entity Type:Organization
Organization Name:MJA HEALTHCARE OF FLORIDA, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MIKHAIL
Authorized Official - Middle Name:
Authorized Official - Last Name:ARTAMONOV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:570-241-9224
Mailing Address - Street 1:391 E BROWN ST
Mailing Address - Street 2:
Mailing Address - City:EAST STROUDSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18301-9101
Mailing Address - Country:US
Mailing Address - Phone:570-241-9224
Mailing Address - Fax:570-872-9888
Practice Address - Street 1:912 S. RIDGEWOOD AVENUE
Practice Address - Street 2:SUITE D
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114
Practice Address - Country:US
Practice Address - Phone:570-872-9800
Practice Address - Fax:570-872-9888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-22
Last Update Date:2014-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD424898174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAI18217Medicare UPIN