MEDICARE: JACKSONVILLE KIDS PEDIATRICS 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	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1083871404
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JACKSONVILLE KIDS PEDIATRICS LLC

Provider Business Mailing Address
First Line	:	13743 SAXON LAKE DR
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32225-2624
Country	:	US
Telephone Number	:	904-253-3459
Fax Number	:

Provider Business Practice Location Address
First Line	:	7807 BAYMEADOWS RD E
Second Line	:	SUITE 207
City	:	JACKSONVILLE
State	:	FL
Zip	:	32256-9664
Country	:	US
Telephone Number	:	904-253-3459
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ALEXANDRA MARY KOSTUR
Credential	:	M.D.
Telephone Number	:	904-253-3459

Provider Enumeration Date	:	05/22/2008
Last Update Date	:	05/22/2008

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