Provider Demographics
NPI:1760654370
Name:ST AUGUSTINE PRIMARY CARE P L
Entity Type:Organization
Organization Name:ST AUGUSTINE PRIMARY CARE P L
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:RAYMAKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-342-2989
Mailing Address - Street 1:PO BOX 3123
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32085-3123
Mailing Address - Country:US
Mailing Address - Phone:904-342-2989
Mailing Address - Fax:904-826-6243
Practice Address - Street 1:105 MARINER HEALTH WAY STE 203
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-3251
Practice Address - Country:US
Practice Address - Phone:904-342-2989
Practice Address - Fax:904-824-6243
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-24
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL40261207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDO0780OtherRR MEDICARE
FLDO0780OtherRR MEDICARE
FLH69033Medicare UPIN