Healthcare Provider Details

I. General information

NPI: 1750448163
Provider Name (Legal Business Name): PHYSICIAN ASSOCIATES OF JACKSONVILLE, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 02/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 RIVERSIDE AVENUE SUITE#14
JACKSONVILLE FL
32205
US

IV. Provider business mailing address

PO BOX 54246
JACKSONVILLE FL
32245
US

V. Phone/Fax

Practice location:
  • Phone: 904-389-3770
  • Fax: 904-389-3703
Mailing address:
  • Phone: 904-389-3770
  • Fax: 904-389-3703

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberME741014
License Number StateFL

VIII. Authorized Official

Name: DR. NAG RAVICHANDRAN
Title or Position: ADMINISTRATOR
Credential: M.D.
Phone: 904-389-3770