Provider Demographics
NPI:1487724993
Name:N E FLORIDA INTERNAL MEDICINE PA
Entity type:Organization
Organization Name:N E FLORIDA INTERNAL MEDICINE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ELYSSA
Authorized Official - Middle Name:
Authorized Official - Last Name:BLISSENBACH
Authorized Official - Suffix:
Authorized Official - Credentials:MD PA
Authorized Official - Phone:904-387-4050
Mailing Address - Street 1:2065 HERSCHEL STREET
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-3817
Mailing Address - Country:US
Mailing Address - Phone:904-387-4050
Mailing Address - Fax:904-387-4860
Practice Address - Street 1:2065 HERSCHEL ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-3817
Practice Address - Country:US
Practice Address - Phone:904-387-4050
Practice Address - Fax:904-387-4860
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2010-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL252461900Medicaid
FLG62748Medicare UPIN
FL252461900Medicaid