Provider Demographics
NPI:1417083171
Name:MCCAULIE PRIMARY CARE P A
Entity Type:Organization
Organization Name:MCCAULIE PRIMARY CARE P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:MCCAULIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-280-5700
Mailing Address - Street 1:520 A1A N
Mailing Address - Street 2:SUITE 201
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-5212
Mailing Address - Country:US
Mailing Address - Phone:904-280-5700
Mailing Address - Fax:904-280-5703
Practice Address - Street 1:520 A1A N
Practice Address - Street 2:SUITE 201
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-5212
Practice Address - Country:US
Practice Address - Phone:904-280-5700
Practice Address - Fax:904-280-5703
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2011-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 000054470207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL378911000Medicaid
FL378911000Medicaid
FLK3401Medicare ID - Type Unspecified