Provider Demographics
NPI:1215080809
Name:FLAGLER FAMILY MEDICINE P A
Entity type:Organization
Organization Name:FLAGLER FAMILY MEDICINE P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNTS RECEVIABLE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:RUTH
Authorized Official - Middle Name:J
Authorized Official - Last Name:FAIRCLOTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-826-3469
Mailing Address - Street 1:130 HEALTH PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-5776
Mailing Address - Country:US
Mailing Address - Phone:904-826-3469
Mailing Address - Fax:904-808-4608
Practice Address - Street 1:130 HEALTH PARK BLVD
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5776
Practice Address - Country:US
Practice Address - Phone:904-826-3469
Practice Address - Fax:904-808-4608
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCD6611OtherPALMETTO GBA RAILROAD MED
FL252488100Medicaid
FL252488100Medicaid