Provider Demographics
NPI:1932180452
Name:CHILDREN'S MEDICAL GROUP PA
Entity Type:Organization
Organization Name:CHILDREN'S MEDICAL GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:FRANKLIN
Authorized Official - Last Name:ZIMMERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:907-268-6725
Mailing Address - Street 1:4131 UNIVERSITY BLVD S
Mailing Address - Street 2:16
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-4326
Mailing Address - Country:US
Mailing Address - Phone:907-733-7408
Mailing Address - Fax:904-733-7668
Practice Address - Street 1:4131 UNIVERSITY BLVD S
Practice Address - Street 2:16
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-4326
Practice Address - Country:US
Practice Address - Phone:907-733-7408
Practice Address - Fax:904-733-7668
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL00149OtherBCBS