Healthcare Provider Details

I. General information

NPI: 1528068624
Provider Name (Legal Business Name): FIRST COAST GASTROENTEROLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2005
Last Update Date: 10/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 WHETSTONE PL SUITE 105
ST AUGUSTINE FL
32086-5773
US

IV. Provider business mailing address

100 WHETSTONE PL SUITE 105
ST AUGUSTINE FL
32086-5773
US

V. Phone/Fax

Practice location:
  • Phone: 904-829-9557
  • Fax: 904-829-9125
Mailing address:
  • Phone: 904-829-9557
  • Fax: 904-829-9125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberME90376
License Number StateFL

VIII. Authorized Official

Name: DR. BENOIT C PINEAU
Title or Position: AUTHORIZED OFFICIAL
Credential: MD
Phone: 904-829-9557