=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699809459
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VASCULAR SURGERY ASSOCIATES OF NORTH FLORIDA PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/15/2007
-----------------------------------------------------
Last Update Date | 08/09/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2140 KINGSLEY AVE SUITE 14
-----------------------------------------------------
City | ORANGE PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32073-5180
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-276-7997
-----------------------------------------------------
Fax | 904-276-7559
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2140 KINGSLEY AVE SUITE 14
-----------------------------------------------------
City | ORANGE PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32073-5180
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-276-7997
-----------------------------------------------------
Fax | 904-276-7559
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | RHONDA L HODGSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 904-276-9514
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | ME0041529
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------