Provider Demographics
NPI:1609543503
Name:NORTHEAST FLORIDA HEALTH SERVICES, INC.
Entity Type:Organization
Organization Name:NORTHEAST FLORIDA HEALTH SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING/CONTRACTS ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:COLLIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-202-6025
Mailing Address - Street 1:1205 S WOODLAND BLVD STE 3
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720-7464
Mailing Address - Country:US
Mailing Address - Phone:386-202-6025
Mailing Address - Fax:
Practice Address - Street 1:216 FREDERICK ST
Practice Address - Street 2:
Practice Address - City:PIERSON
Practice Address - State:FL
Practice Address - Zip Code:32180-3024
Practice Address - Country:US
Practice Address - Phone:386-749-9449
Practice Address - Fax:386-749-9447
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHEAST FLORIDA HEALTH SERVICES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-08-27
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL687955101Medicaid