Provider Demographics
NPI:1821299637
Name:NORTHEAST FLORIDA ENDOCRINE AND DIABETES ASSOCIATES PA
Entity Type:Organization
Organization Name:NORTHEAST FLORIDA ENDOCRINE AND DIABETES ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:EILEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN FOSSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-384-2240
Mailing Address - Street 1:580 W 8TH ST
Mailing Address - Street 2:SUITE 6005
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32209-6533
Mailing Address - Country:US
Mailing Address - Phone:904-384-2240
Mailing Address - Fax:904-244-9607
Practice Address - Street 1:580 W 8TH ST
Practice Address - Street 2:SUITE 6005
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-6533
Practice Address - Country:US
Practice Address - Phone:904-384-2240
Practice Address - Fax:904-244-9607
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-30
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL374606200Medicaid
FL77240Medicare ID - Type Unspecified