Healthcare Provider Details

I. General information

NPI: 1053005348
Provider Name (Legal Business Name): FIRST COAST ORTHOPEDIC ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2023
Last Update Date: 06/08/2023
Certification Date: 06/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6067 KENNERLY RD
JACKSONVILLE FL
32216-4305
US

IV. Provider business mailing address

3701 WINDMOOR DR
JACKSONVILLE FL
32217-4240
US

V. Phone/Fax

Practice location:
  • Phone: 904-731-3131
  • Fax:
Mailing address:
  • Phone: 904-388-4712
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. HAISSAM BARAKAT
Title or Position: CREDENTIALING
Credential:
Phone: 904-962-6005