Provider Demographics
NPI:1952503567
Name:FLORIDA CLINICAL PRACTICE ASSOCIATION INC
Entity Type:Organization
Organization Name:FLORIDA CLINICAL PRACTICE ASSOCIATION INC
Other - Org Name:PEDIATRIC NEONATOLOGY GROUP
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:
Authorized Official - Last Name:SIBISKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-265-8017
Mailing Address - Street 1:PO BOX 13833
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19101-3833
Mailing Address - Country:US
Mailing Address - Phone:352-392-4195
Mailing Address - Fax:352-392-4533
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:# 100296
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-0296
Practice Address - Country:US
Practice Address - Phone:352-273-8985
Practice Address - Fax:352-392-4533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-05
Last Update Date:2016-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0533866012080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL053386601Medicaid