MEDICARE: BEACHSIDE PRIMARY CARE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2300X	Primary Care Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1386364032
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BEACHSIDE PRIMARY CARE LLC

Provider Business Mailing Address
First Line	:	1825 3RD ST N STE B
Second Line	:
City	:	JACKSONVILLE BEACH
State	:	FL
Zip	:	32250-4840
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1825 3RD ST N STE B
Second Line	:
City	:	JACKSONVILLE BEACH
State	:	FL
Zip	:	32250-4840
Country	:	US
Telephone Number	:	904-595-5826
Fax Number	:	904-595-5827

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. DEBORAH GHANDOUR
Credential	:	PA-C, DHSC
Telephone Number	:	904-595-5826

Provider Enumeration Date	:	09/01/2022
Last Update Date	:	12/16/2022

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Directions to “BEACHSIDE PRIMARY CARE LLC ” Practice Location

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