MEDICARE: BEACHES EAR, NOSE AND THROAT, PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	231HA2400X	Assistive Technology Practitioner Audiologist	AY1951	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1013391275
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BEACHES EAR, NOSE AND THROAT, PA

Provider Business Mailing Address
First Line	:	PO BOX 3217
Second Line	:
City	:	PONTE VEDRA BEACH
State	:	FL
Zip	:	32004-3217
Country	:	US
Telephone Number	:	904-247-4070
Fax Number	:	904-247-4131

Provider Business Practice Location Address
First Line	:	3200 3RD ST S
Second Line	:	SUITE 101
City	:	JACKSONVILLE BEACH
State	:	FL
Zip	:	32250-6096
Country	:	US
Telephone Number	:	904-247-4070
Fax Number	:	904-247-4131

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JEFFREY E BRINK
Credential	:	M.D.
Telephone Number	:	904-247-4070

Provider Enumeration Date	:	07/16/2015
Last Update Date	:	07/16/2015

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