Healthcare Provider Details

I. General information

NPI: 1407038169
Provider Name (Legal Business Name): PRIMECARE PL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2007
Last Update Date: 11/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2720 US HIGHWAY 1 S # B
ST AUGUSTINE FL
32086-6301
US

IV. Provider business mailing address

2720 US HIGHWAY 1 S # B
ST AUGUSTINE FL
32086-6301
US

V. Phone/Fax

Practice location:
  • Phone: 904-827-0078
  • Fax: 904-827-0140
Mailing address:
  • Phone: 904-827-0078
  • Fax: 904-827-0140

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberME58662
License Number StateFL

VIII. Authorized Official

Name: ROBERT C KELSEY
Title or Position: PRESIDENT
Credential: MD
Phone: 904-827-0078