Provider Demographics
NPI:1760881163
Name:FIRST COAST MEDICAL ASSOCIATES LLC
Entity Type:Organization
Organization Name:FIRST COAST MEDICAL ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTO
Authorized Official - Prefix:
Authorized Official - First Name:RAVI
Authorized Official - Middle Name:K
Authorized Official - Last Name:KANCHA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-400-6800
Mailing Address - Street 1:13241 BARTRAM PARK BLVD UNIT 413
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32258-5237
Mailing Address - Country:US
Mailing Address - Phone:904-400-6800
Mailing Address - Fax:904-400-6801
Practice Address - Street 1:13241 BARTRAM PARK BLVD UNIT 413
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-5237
Practice Address - Country:US
Practice Address - Phone:904-400-6800
Practice Address - Fax:904-400-6801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-21
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X
FLME98044305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No305R00000XManaged Care OrganizationsPreferred Provider OrganizationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL277639100Medicaid
FL277639100Medicaid