Provider Demographics
NPI:1497885149
Name:FLORIDA UROGYNECOLOGY AND RECONSTRUCTIVE PELVIC SURGERY PA
Entity Type:Organization
Organization Name:FLORIDA UROGYNECOLOGY AND RECONSTRUCTIVE PELVIC SURGERY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:R
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-653-0373
Mailing Address - Street 1:6885 BELFORT OAKS PL
Mailing Address - Street 2:SUITE 210
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-6234
Mailing Address - Country:US
Mailing Address - Phone:904-652-0373
Mailing Address - Fax:904-652-0378
Practice Address - Street 1:6885 BELFORT OAKS PL
Practice Address - Street 2:SUITE 210
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-6234
Practice Address - Country:US
Practice Address - Phone:904-652-0373
Practice Address - Fax:904-652-0378
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK6278Medicare PIN