Provider Demographics
NPI:1932202322
Name:NORTHEAST FLORIDA STATE HOSPITAL
Entity Type:Organization
Organization Name:NORTHEAST FLORIDA STATE HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:OLGA
Authorized Official - Middle Name:INES
Authorized Official - Last Name:ARIAS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:904-259-6211
Mailing Address - Street 1:7487 S STATE ROAD 121
Mailing Address - Street 2:
Mailing Address - City:MACCLENNY
Mailing Address - State:FL
Mailing Address - Zip Code:32063-5451
Mailing Address - Country:US
Mailing Address - Phone:904-259-6211
Mailing Address - Fax:904-259-7104
Practice Address - Street 1:7487 S STATE ROAD 121
Practice Address - Street 2:
Practice Address - City:MACCLENNY
Practice Address - State:FL
Practice Address - Zip Code:32063-5451
Practice Address - Country:US
Practice Address - Phone:904-259-6211
Practice Address - Fax:904-259-7104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS 75472084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric PsychiatryGroup - Multi-Specialty