MEDICARE: PEDIATRIC ASSOCIATES OF JACKSONVILLE, 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	208000000X	Pediatrics Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	99995	OTHER		BLUECROSS BLUESHIELD

General Provider Information

NPI Number	:	1811954126
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDIATRIC ASSOCIATES OF JACKSONVILLE, PA

Provider Business Mailing Address
First Line	:	2 FAIRFIELD BLVD
Second Line	:	SUITE #11
City	:	PONTE VEDRA BEACH
State	:	FL
Zip	:	32082-4626
Country	:	US
Telephone Number	:	904-273-6533
Fax Number	:	904-280-7369

Provider Business Practice Location Address
First Line	:	2 FAIRFIELD BLVD
Second Line	:	SUITE #11
City	:	PONTE VEDRA BEACH
State	:	FL
Zip	:	32082-4626
Country	:	US
Telephone Number	:	904-273-6533
Fax Number	:	904-280-7369

Authorized Official
Title or Position	:	PEDIATRICIAN/PRESIDENT
Name	:	DR. AYLIN OZDEMIR
Credential	:	M.D.
Telephone Number	:	904-273-6533

Provider Enumeration Date	:	04/28/2006
Last Update Date	:	03/07/2008

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