MEDICARE: FIRST COAST ORTHOPEDIC ASSOCIATES LLC

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	207RS0010X	Sports Medicine (Internal Medicine) Physician

General Provider Information

NPI Number	:	1053005348
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FIRST COAST ORTHOPEDIC ASSOCIATES LLC

Provider Business Mailing Address
First Line	:	3701 WINDMOOR DR
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32217-4240
Country	:	US
Telephone Number	:	904-388-4712
Fax Number	:

Provider Business Practice Location Address
First Line	:	6067 KENNERLY RD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32216-4305
Country	:	US
Telephone Number	:	904-731-3131
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING
Name	:	MR. HAISSAM BARAKAT
Credential	:
Telephone Number	:	904-962-6005

Provider Enumeration Date	:	06/08/2023
Last Update Date	:	06/08/2023

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