Provider Demographics
NPI:1417264722
Name:FIRST COAST PODIATRIC SURGERY AND WOUND CARE LLC
Entity Type:Organization
Organization Name:FIRST COAST PODIATRIC SURGERY AND WOUND CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JORG
Authorized Official - Middle Name:ALEXANDER
Authorized Official - Last Name:BOBER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:904-422-1566
Mailing Address - Street 1:PO BOX 1653
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32067-1653
Mailing Address - Country:US
Mailing Address - Phone:904-637-0037
Mailing Address - Fax:
Practice Address - Street 1:3599 UNIVERSITY BLVD S
Practice Address - Street 2:SUITE 504
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-7411
Practice Address - Country:US
Practice Address - Phone:904-637-0037
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-08
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO 3294213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty