Provider Demographics
NPI:1720285125
Name:TOWNSEND CLINIC PA
Entity Type:Organization
Organization Name:TOWNSEND CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:EDWIN
Authorized Official - Last Name:TOWNSEND
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:904-461-1901
Mailing Address - Street 1:4475 US HIGHWAY 1 S
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-7284
Mailing Address - Country:US
Mailing Address - Phone:904-461-1901
Mailing Address - Fax:904-461-1902
Practice Address - Street 1:4475 US HWY 1 SOUTH
Practice Address - Street 2:SUITE 100
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-7200
Practice Address - Country:US
Practice Address - Phone:904-461-1901
Practice Address - Fax:904-461-1902
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TOWNSEND CLINIC PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-06-28
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0058357207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK9283Medicare PIN