Provider Demographics
NPI:1528197993
Name:FIRST COAST PRIMARY CARE INC
Entity Type:Organization
Organization Name:FIRST COAST PRIMARY CARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATION MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:E
Authorized Official - Last Name:GOODEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-400-6100
Mailing Address - Street 1:PO BOX 61148
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32236-1148
Mailing Address - Country:US
Mailing Address - Phone:904-400-6100
Mailing Address - Fax:904-400-6102
Practice Address - Street 1:4040 WOODCOCK DR
Practice Address - Street 2:SUITE 250
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-2720
Practice Address - Country:US
Practice Address - Phone:904-400-6103
Practice Address - Fax:904-400-6102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-03
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAC716Medicare PIN