Provider Demographics
NPI:1417905993
Name:SOUTHEAST GYNECOLOGIC ONCOLOGY ASSOCIATES PA
Entity Type:Organization
Organization Name:SOUTHEAST GYNECOLOGIC ONCOLOGY ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-389-3993
Mailing Address - Street 1:915 W MONROE ST
Mailing Address - Street 2:#300
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-1149
Mailing Address - Country:US
Mailing Address - Phone:904-389-3993
Mailing Address - Fax:904-389-3994
Practice Address - Street 1:915 W MONROE ST
Practice Address - Street 2:#300
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-1149
Practice Address - Country:US
Practice Address - Phone:904-389-3993
Practice Address - Fax:904-389-3994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-05
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL45542Medicare PIN