Provider Demographics
NPI:1548429590
Name:JERROLD ECKLIND DO PA
Entity Type:Organization
Organization Name:JERROLD ECKLIND DO PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JERROLD
Authorized Official - Middle Name:RANDALL
Authorized Official - Last Name:ECKLINDS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:386-615-8300
Mailing Address - Street 1:555 W GRANADA BLVD
Mailing Address - Street 2:SUITE D-2
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-9485
Mailing Address - Country:US
Mailing Address - Phone:386-615-8300
Mailing Address - Fax:386-677-1818
Practice Address - Street 1:555 W GRANADA BLVD
Practice Address - Street 2:SUITE D-2
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-9485
Practice Address - Country:US
Practice Address - Phone:386-615-8300
Practice Address - Fax:386-677-1818
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-05
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS7663261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1851390322OtherNPI
FL49221OtherBLUE CROSS BLUE SHIELD
FLE1206Medicare PIN
FL49221OtherBLUE CROSS BLUE SHIELD