Healthcare Provider Details

I. General information

NPI: 1073796660
Provider Name (Legal Business Name): JACKSONVILLE CRITICAL CARE ASSOCIATES PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2007
Last Update Date: 11/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6817 SOUTHPOINT PKWY SUITE 801
JACKSONVILLE FL
32216-6282
US

IV. Provider business mailing address

8253 RIDING CLUB RD
JACKSONVILLE FL
32256-7262
US

V. Phone/Fax

Practice location:
  • Phone: 904-646-3420
  • Fax: 904-646-3017
Mailing address:
  • Phone: 904-646-3420
  • Fax: 904-646-3017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberME51611
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberME51611
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME51611
License Number StateFL

VIII. Authorized Official

Name: DR. KASRA A NABIZADEH
Title or Position: PRESIDENT
Credential: M.D.
Phone: 904-646-5505