Provider Demographics
NPI:1336170422
Name:CRITICAL CARE OF N JACKSONVILLE, PA
Entity Type:Organization
Organization Name:CRITICAL CARE OF N JACKSONVILLE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:MRS
Authorized Official - First Name:EVA
Authorized Official - Middle Name:V
Authorized Official - Last Name:JACKLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-739-6666
Mailing Address - Street 1:PO BOX 56917
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32241-6917
Mailing Address - Country:US
Mailing Address - Phone:904-739-6666
Mailing Address - Fax:904-739-1009
Practice Address - Street 1:3550 UNIVERSITY BLVD S
Practice Address - Street 2:SUITE 207
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-4246
Practice Address - Country:US
Practice Address - Phone:904-739-6666
Practice Address - Fax:904-739-1009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL38709OtherBCBSFL
FL38709OtherBCBSFL