Healthcare Provider Details

I. General information

NPI: 1104347020
Provider Name (Legal Business Name): FLAGLER PROFESSIONAL HEALTH CARE SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2017
Last Update Date: 07/31/2020
Certification Date: 07/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 HEALTH PARK BLVD STE 1
SAINT AUGUSTINE FL
32086-5798
US

IV. Provider business mailing address

120 HEALTH PARK BLVD STE 1
SAINT AUGUSTINE FL
32086-5798
US

V. Phone/Fax

Practice location:
  • Phone: 904-823-3401
  • Fax: 904-829-8649
Mailing address:
  • Phone: 904-819-4602
  • Fax: 904-819-4426

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JASON BARRETT
Title or Position: HOSPITAL PRESIDENT
Credential:
Phone: 904-819-4400