Provider Demographics
NPI:1972555316
Name:LTR MEDICAL MANAGEMENT GROUP INC
Entity Type:Organization
Organization Name:LTR MEDICAL MANAGEMENT GROUP INC
Other - Org Name:FIRST COAST PHYSICAL MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JANET
Authorized Official - Middle Name:L
Authorized Official - Last Name:STEPHENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-727-7733
Mailing Address - Street 1:PO BOX 55065
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-0065
Mailing Address - Country:US
Mailing Address - Phone:904-727-7733
Mailing Address - Fax:904-727-7737
Practice Address - Street 1:3101 UNIVERSITY BLVD S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-2750
Practice Address - Country:US
Practice Address - Phone:904-727-7733
Practice Address - Fax:904-727-7737
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK5391Medicare ID - Type Unspecified