Provider Demographics
NPI:1750448163
Name:PHYSICIAN ASSOCIATES OF JACKSONVILLE, PA
Entity Type:Organization
Organization Name:PHYSICIAN ASSOCIATES OF JACKSONVILLE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:NAG
Authorized Official - Middle Name:
Authorized Official - Last Name:RAVICHANDRAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-389-3770
Mailing Address - Street 1:PO BOX 54246
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32245
Mailing Address - Country:US
Mailing Address - Phone:904-389-3770
Mailing Address - Fax:904-389-3703
Practice Address - Street 1:2700 RIVERSIDE AVENUE
Practice Address - Street 2:SUITE#14
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32205
Practice Address - Country:US
Practice Address - Phone:904-389-3770
Practice Address - Fax:904-389-3703
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2012-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME741014207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK1498Medicare PIN