Provider Demographics
NPI:1558798405
Name:NORTHEAST FLORIDA PSYCHIATRIC ASSOCIATION, INC
Entity Type:Organization
Organization Name:NORTHEAST FLORIDA PSYCHIATRIC ASSOCIATION, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:W
Authorized Official - Last Name:FRICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-767-8584
Mailing Address - Street 1:790 DUNLAWTON AVE.
Mailing Address - Street 2:SUITE J
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-4222
Mailing Address - Country:US
Mailing Address - Phone:386-767-8584
Mailing Address - Fax:386-767-8536
Practice Address - Street 1:790 DUNLAWTON AVE
Practice Address - Street 2:SUITE J
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-4222
Practice Address - Country:US
Practice Address - Phone:386-767-8584
Practice Address - Fax:386-767-8536
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-07
Last Update Date:2014-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME733162084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2526671-00Medicaid
FL2526671-00Medicaid
FL2526671-00Medicaid
41940XMedicare PIN
FL41940BMedicare PIN