Provider Demographics
NPI:1588319925
Name:MISS CENTER OF EXCELLENCE PA
Entity type:Organization
Organization Name:MISS CENTER OF EXCELLENCE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:F
Authorized Official - Last Name:CANNESTRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-343-1185
Mailing Address - Street 1:4530-15 ST JOHNS AVENUE 396
Mailing Address - Street 2:396
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32210
Mailing Address - Country:US
Mailing Address - Phone:904-451-7144
Mailing Address - Fax:
Practice Address - Street 1:4530-15 ST JOHNS AVENUE 396
Practice Address - Street 2:396
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210
Practice Address - Country:US
Practice Address - Phone:904-451-7144
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-15
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty