Healthcare Provider Details

I. General information

NPI: 1710286067
Provider Name (Legal Business Name): FIRST COAST OBSTETRICS AND GYNECOLOGY PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2011
Last Update Date: 09/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6100 SAINT JOHNS AVE SUITE 6
PALATKA FL
32177
US

IV. Provider business mailing address

6100 SAINT JOHNS AVE STE 6
PALATKA FL
32177-6859
US

V. Phone/Fax

Practice location:
  • Phone: 386-325-5699
  • Fax:
Mailing address:
  • Phone: 386-325-5699
  • Fax: 386-325-5644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. LUCIEN - MAXIMIN YANOU TCHUISSE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 386-325-5699