Provider Demographics
NPI:1568798965
Name:ST AUGUSTINE PHYSICAL MEDICINE
Entity Type:Organization
Organization Name:ST AUGUSTINE PHYSICAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:L
Authorized Official - Last Name:SOLANA
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:904-429-7071
Mailing Address - Street 1:1100 S PONCE DE LEON BLVD
Mailing Address - Street 2:SUITE 3-A
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32084-6099
Mailing Address - Country:US
Mailing Address - Phone:904-429-7071
Mailing Address - Fax:
Practice Address - Street 1:1100 S PONCE DE LEON BLVD
Practice Address - Street 2:SUITE 3-A
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-6099
Practice Address - Country:US
Practice Address - Phone:904-429-7071
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-20
Last Update Date:2009-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care