Provider Demographics
NPI:1215158035
Name:NORTH FLORIDA ID P L
Entity type:Organization
Organization Name:NORTH FLORIDA ID P L
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:W
Authorized Official - Last Name:YANCEY JR.
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-375-0819
Mailing Address - Street 1:7257 NW 4TH BLVD
Mailing Address - Street 2:#43
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32607-1600
Mailing Address - Country:US
Mailing Address - Phone:352-375-0819
Mailing Address - Fax:352-373-6775
Practice Address - Street 1:7257 NW 4TH BLVD
Practice Address - Street 2:#43
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32607-1600
Practice Address - Country:US
Practice Address - Phone:352-375-0819
Practice Address - Fax:352-373-6775
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2007-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0045380174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME0045380OtherMEDICAL LICENSE
FLME0045380OtherMEDICAL LICENSE