=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871812016
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHARLES P. ADAMS JR., MD PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/27/2010
-----------------------------------------------------
Last Update Date | 05/27/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1034 RIVERSIDE AVE
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32204-4123
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-354-2114
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1034 RIVERSIDE AVE
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32204-4123
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-354-2114
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | CHARLES P ADAMS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 904-354-2114
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | ME45165
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------