Provider Demographics
NPI:1790832210
Name:NORTH FLORIDA OBSTETRIC & GYN CENTER PA
Entity Type:Organization
Organization Name:NORTH FLORIDA OBSTETRIC & GYN CENTER PA
Other - Org Name:DR BRYCE V JACKSON
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYCE
Authorized Official - Middle Name:VINCENT
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-784-6877
Mailing Address - Street 1:1937 HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-4543
Mailing Address - Country:US
Mailing Address - Phone:850-784-6877
Mailing Address - Fax:850-785-5346
Practice Address - Street 1:1937 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-4543
Practice Address - Country:US
Practice Address - Phone:850-784-6877
Practice Address - Fax:850-785-5346
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME48532174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL03638OtherBLUE CROSS BLUE SHIELD
FL043532500Medicaid
FL03638Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
FL043532500Medicaid