Provider Demographics
NPI:1285938936
Name:MEDICAL SPECIALISTS OF NORTHEAST FLORIDA PLLC
Entity type:Organization
Organization Name:MEDICAL SPECIALISTS OF NORTHEAST FLORIDA PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:SHRIRAM
Authorized Official - Middle Name:
Authorized Official - Last Name:MARATHE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-484-5176
Mailing Address - Street 1:6428 BEACH BLVD STE 1A
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-2813
Mailing Address - Country:US
Mailing Address - Phone:904-475-2039
Mailing Address - Fax:904-330-0668
Practice Address - Street 1:6428 BEACH BLVD STE 1A
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-2813
Practice Address - Country:US
Practice Address - Phone:904-342-0816
Practice Address - Fax:904-342-0553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-10
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207U00000XAllopathic & Osteopathic PhysiciansNuclear MedicineGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ES318AMedicare PIN