Healthcare Provider Details

I. General information

NPI: 1730549817
Provider Name (Legal Business Name): PHYSICIAN ASSOCIATES GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2016
Last Update Date: 03/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 PLANTATION ISLAND DR S SUITE 201-A
ST AUGUSTINE FL
32080-3108
US

IV. Provider business mailing address

1301 PLANTATION ISLAND DR S SUITE 201-A
ST AUGUSTINE FL
32080-3108
US

V. Phone/Fax

Practice location:
  • Phone: 904-342-5965
  • Fax:
Mailing address:
  • Phone: 904-342-5965
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License NumberME88707
License Number StateFL

VIII. Authorized Official

Name: JEREMY MIRABILE
Title or Position: MEDICAL DOCTOR
Credential: MD
Phone: 904-342-5965