Provider Demographics
NPI:1568514503
Name:FIRST CHOICE FAMILY PRACTICE PA
Entity Type:Organization
Organization Name:FIRST CHOICE FAMILY PRACTICE PA
Other - Org Name:FIRST CHOICE MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:CANNON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-269-2900
Mailing Address - Street 1:550 WELLS RD
Mailing Address - Street 2:SUITE 17
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-2969
Mailing Address - Country:US
Mailing Address - Phone:904-269-2900
Mailing Address - Fax:904-269-1140
Practice Address - Street 1:550 WELLS RD
Practice Address - Street 2:SUITE 17
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-2969
Practice Address - Country:US
Practice Address - Phone:904-269-2900
Practice Address - Fax:904-269-1140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0052191207Q00000X
FLOS7923207Q00000X
FLPA2719363A00000X
FLPA9101422363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Not Answered363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL05937OtherBCBS
FL24536Medicare ID - Type Unspecified