Healthcare Provider Details

I. General information

NPI: 1104895473
Provider Name (Legal Business Name): GREGORY F MACISAAC MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2006
Last Update Date: 02/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 CYPRESS EDGE DR SUITE 210
PALM COAST FL
32164-8453
US

IV. Provider business mailing address

120 CYPRESS EDGE DR SUITE 210
PALM COAST FL
32164-8453
US

V. Phone/Fax

Practice location:
  • Phone: 386-445-4750
  • Fax: 386-445-4751
Mailing address:
  • Phone: 386-445-4750
  • Fax: 386-445-4751

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101057756
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: