MEDICARE: CHILDREN'S EXPRESS CARE CLINIC

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	208000000X	Pediatrics Physician

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	:	1538735246
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHILDREN'S EXPRESS CARE CLINIC

Provider Business Mailing Address
First Line	:	135 DURBIN STATION CT UNIT 503
Second Line	:
City	:	ST JOHNS
State	:	FL
Zip	:	32259-9370
Country	:	US
Telephone Number	:	904-519-0008
Fax Number	:

Provider Business Practice Location Address
First Line	:	135 DURBIN STATION CT UNIT 503
Second Line	:
City	:	ST JOHNS
State	:	FL
Zip	:	32259-9370
Country	:	US
Telephone Number	:	904-519-0008
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	SUWARNA M TILAK
Credential	:	MD
Telephone Number	:	904-519-0008

Provider Enumeration Date	:	06/02/2021
Last Update Date	:	06/08/2021

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Directions to “CHILDREN'S EXPRESS CARE CLINIC ” Practice Location

Language	Start Address	Practice Location

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