Provider Demographics
NPI:1538146048
Name:BIANCHI, PATRICK DEVERELL
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:DEVERELL
Last Name:BIANCHI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3700 CAHABA BEACH RD
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35242-5225
Mailing Address - Country:US
Mailing Address - Phone:205-403-8902
Mailing Address - Fax:205-271-5590
Practice Address - Street 1:11513 N MAIN ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-4002
Practice Address - Country:US
Practice Address - Phone:904-751-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME74033174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL045038300Medicaid
FLC73046Medicare UPIN
FL045038300Medicaid