Healthcare Provider Details

I. General information

NPI: 1083769749
Provider Name (Legal Business Name): EYYUNNI PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 08/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 HEALTH PARK BLVD SUITE 107
ST AUGUSTINE FL
32086-5796
US

IV. Provider business mailing address

PO BOX 3123
ST AUGUSTINE FL
32085-3123
US

V. Phone/Fax

Practice location:
  • Phone: 904-819-0101
  • Fax:
Mailing address:
  • Phone: 904-824-4990
  • Fax: 904-824-2226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberME82671
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberME81943
License Number StateFL

VIII. Authorized Official

Name: RAMANUJAM EYYUNNI
Title or Position: OWNER
Credential: MD
Phone: 904-819-0101