Provider Demographics
NPI:1639126907
Name:NORTH FLORIDA MEDICAL CLINIC INC
Entity Type:Organization
Organization Name:NORTH FLORIDA MEDICAL CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HOLTHAUS
Authorized Official - Middle Name:
Authorized Official - Last Name:KEVIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-242-7177
Mailing Address - Street 1:PO BOX 17809
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32245-7809
Mailing Address - Country:US
Mailing Address - Phone:904-723-0015
Mailing Address - Fax:904-338-0951
Practice Address - Street 1:1361 13TH AVE S STE 150
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-3235
Practice Address - Country:US
Practice Address - Phone:904-242-7177
Practice Address - Fax:904-242-7162
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-30
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME43785207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL94954OtherBCBS
1639126907OtherNPI
FLDD6503OtherRAILROAD MEDICARE
FL94954Medicare PIN