Provider Demographics
NPI:1891069449
Name:PHYSICIANS MEDICAL CENTER NORTHSIDE INC
Entity Type:Organization
Organization Name:PHYSICIANS MEDICAL CENTER NORTHSIDE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:EDGAR
Authorized Official - Last Name:KERSEY
Authorized Official - Suffix:JR
Authorized Official - Credentials:DD
Authorized Official - Phone:904-757-2527
Mailing Address - Street 1:1840 DUNN AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218-4799
Mailing Address - Country:US
Mailing Address - Phone:904-757-2527
Mailing Address - Fax:904-757-3656
Practice Address - Street 1:1840 DUNN AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-4799
Practice Address - Country:US
Practice Address - Phone:904-757-2527
Practice Address - Fax:904-757-3656
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-29
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLFL7438111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
U58582Medicare UPIN