Healthcare Provider Details

I. General information

NPI: 1932202322
Provider Name (Legal Business Name): NORTHEAST FLORIDA STATE HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7487 S STATE ROAD 121
MACCLENNY FL
32063-5451
US

IV. Provider business mailing address

7487 S STATE ROAD 121
MACCLENNY FL
32063-5451
US

V. Phone/Fax

Practice location:
  • Phone: 904-259-6211
  • Fax: 904-259-7104
Mailing address:
  • Phone: 904-259-6211
  • Fax: 904-259-7104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License NumberOS 7547
License Number StateFL

VIII. Authorized Official

Name: DR. OLGA INES ARIAS
Title or Position: SENIOR PHYSICIAN
Credential: D.O.
Phone: 904-259-6211