Provider Demographics
NPI:1477613172
Name:MEMORIAL FAMILY PRACTICE ASSOCIATES
Entity Type:Organization
Organization Name:MEMORIAL FAMILY PRACTICE ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:
Authorized Official - Last Name:BUCKINGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-306-8067
Mailing Address - Street 1:PO BOX 277272
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-7272
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3546 ST JOHNS BLUFF ROAD SOUTH
Practice Address - Street 2:SUITE 108
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224
Practice Address - Country:US
Practice Address - Phone:904-306-8067
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK9462Medicare PIN