=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477500817
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HITEN KISNAD MD PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/30/2006
-----------------------------------------------------
Last Update Date | 07/06/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 320 1ST ST N STE 614
-----------------------------------------------------
City | JACKSONVILLE BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32250-6944
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-270-2217
-----------------------------------------------------
Fax | 904-270-2232
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 320 1ST ST N SUITE 614
-----------------------------------------------------
City | JACKSONVILLE BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32250-6944
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-270-2217
-----------------------------------------------------
Fax | 904-270-2232
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | HITEN V KISNAD
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 904-270-2217
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | ME0066482
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------