MEDICARE: NORTHEAST FLORIDA PSYCHIATRIC ASSOCIATION, INC

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	2084P0800X	Psychiatry Physician	ME73316	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	:	1558798405
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHEAST FLORIDA PSYCHIATRIC ASSOCIATION, INC

Provider Business Mailing Address
First Line	:	804 DUNLAWTON AVE STE 1
Second Line	:
City	:	PORT ORANGE
State	:	FL
Zip	:	32127-4931
Country	:	US
Telephone Number	:	386-767-8584
Fax Number	:	386-767-8536

Provider Business Practice Location Address
First Line	:	804 DUNLAWTON AVE STE 1
Second Line	:
City	:	PORT ORANGE
State	:	FL
Zip	:	32127-4931
Country	:	US
Telephone Number	:	386-767-8584
Fax Number	:	386-767-8536

Authorized Official
Title or Position	:	PROVIDER
Name	:	GARY FRICK
Credential	:	MD
Telephone Number	:	386-767-8584

Provider Enumeration Date	:	10/07/2013
Last Update Date	:	12/16/2025

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