Provider Demographics
NPI:1023311727
Name:OB & GYN OF N E FL PA
Entity type:Organization
Organization Name:OB & GYN OF N E FL PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAILA
Authorized Official - Middle Name:B
Authorized Official - Last Name:NEEDHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-530-2380
Mailing Address - Street 1:PO BOX 658
Mailing Address - Street 2:
Mailing Address - City:PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32178-0658
Mailing Address - Country:US
Mailing Address - Phone:386-530-2380
Mailing Address - Fax:386-530-2381
Practice Address - Street 1:700 ZEAGLER DR
Practice Address - Street 2:STE 3
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177-6806
Practice Address - Country:US
Practice Address - Phone:386-530-2380
Practice Address - Fax:386-530-2381
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-19
Last Update Date:2013-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLEL011AOtherMEDICARE - PALATKA LOCATION
FLEL011BOtherMEDICARE - ST. AUGUSTINE LOCATION
FL000947900Medicaid