Healthcare Provider Details

I. General information

NPI: 1003419763
Provider Name (Legal Business Name): MAINLAND PHYSICIANS GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2020
Last Update Date: 11/17/2020
Certification Date: 11/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 ARRICOLA AVE
ST AUGUSTINE FL
32080-4515
US

IV. Provider business mailing address

100 ARRICOLA AVE
ST AUGUSTINE FL
32080-4515
US

V. Phone/Fax

Practice location:
  • Phone: 904-825-4368
  • Fax: 904-825-9107
Mailing address:
  • Phone: 904-825-4368
  • Fax: 904-825-9107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. JOHN PAUL JAMES SHADDOCK
Title or Position: DIRECTOR OF NETWORK MANAGMENT
Credential:
Phone: 850-341-6322