Provider Demographics
NPI:1659337756
Name:OBGYN ASSOCIATES OF ST AUGUSTINE PA
Entity Type:Organization
Organization Name:OBGYN ASSOCIATES OF ST AUGUSTINE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:YARIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-819-1500
Mailing Address - Street 1:300 HEALTH PARK BLVD
Mailing Address - Street 2:STE 3002
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086
Mailing Address - Country:US
Mailing Address - Phone:904-819-1500
Mailing Address - Fax:904-810-1023
Practice Address - Street 1:300 HEALTH PARK BLVD
Practice Address - Street 2:STE 3002
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086
Practice Address - Country:US
Practice Address - Phone:904-819-1500
Practice Address - Fax:904-810-1023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-26
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0066572207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL264245000Medicaid
FL264245000Medicaid
FLK2703Medicare PIN