MEDICARE: FIRST COAST PRIMARY CARE INC

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	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1528197993
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FIRST COAST PRIMARY CARE INC

Provider Business Mailing Address
First Line	:	PO BOX 61148
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32236-1148
Country	:	US
Telephone Number	:	904-400-6100
Fax Number	:	904-400-6102

Provider Business Practice Location Address
First Line	:	4040 WOODCOCK DR
Second Line	:	SUITE 250
City	:	JACKSONVILLE
State	:	FL
Zip	:	32207-2720
Country	:	US
Telephone Number	:	904-400-6103
Fax Number	:	904-400-6102

Authorized Official
Title or Position	:	ADMINISTRATION MANAGER
Name	:	LINDA E GOODEN
Credential	:
Telephone Number	:	904-400-6100

Provider Enumeration Date	:	03/03/2007
Last Update Date	:	09/28/2011

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