Provider Demographics
NPI:1437637402
Name:PHYSIATRY CONSULTS OF JACKSONVILLE. LLC
Entity Type:Organization
Organization Name:PHYSIATRY CONSULTS OF JACKSONVILLE. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MGR
Authorized Official - Prefix:DR
Authorized Official - First Name:NATALYA
Authorized Official - Middle Name:BULAEVA
Authorized Official - Last Name:BULAEVA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-860-1123
Mailing Address - Street 1:836 BAYTREE LN
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-4162
Mailing Address - Country:US
Mailing Address - Phone:904-860-1123
Mailing Address - Fax:
Practice Address - Street 1:1750 STOCKTON ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4664
Practice Address - Country:US
Practice Address - Phone:190-486-0112
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-01
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003169167AMedicaid