Provider Demographics
NPI:1578664074
Name:PODIATRY ASSOCIATES OF FLORIDA INC
Entity Type:Organization
Organization Name:PODIATRY ASSOCIATES OF FLORIDA INC
Other - Org Name:PODIATRY ASSOCIATES OF NORTHEAST FLORIDA INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CORPORATE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JEANNIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:BASKIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-251-5053
Mailing Address - Street 1:2140 KINGSLEY AVE STE 12
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-5129
Mailing Address - Country:US
Mailing Address - Phone:904-224-2001
Mailing Address - Fax:904-224-2002
Practice Address - Street 1:1361 13TH AVE S
Practice Address - Street 2:STE 120
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-3233
Practice Address - Country:US
Practice Address - Phone:904-224-2001
Practice Address - Fax:904-224-2002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC3124OtherRAILROAD MEDICARE
FL041050100Medicaid
87368OtherBLUE CROSS BLUE SHIELD
65767OtherBCBS
480028094OtherRAILROAD MEDICARE
65207OtherBLUE CROSS BLUE SHIELD
P00249337OtherRAILROAD MEDICARE
P00603529OtherRAILROAD MEDICARE
CI4974OtherRAILROAD MEDICARE
65207OtherBLUE CROSS BLUE SHIELD
21698LMedicare PIN