Provider Demographics
NPI:1720236383
Name:ANCIENT CITY MIDWIVES INC
Entity type:Organization
Organization Name:ANCIENT CITY MIDWIVES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROGERO
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP CNM
Authorized Official - Phone:904-826-1007
Mailing Address - Street 1:PO BOX 3123
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32085-3123
Mailing Address - Country:US
Mailing Address - Phone:904-824-4990
Mailing Address - Fax:904-824-2226
Practice Address - Street 1:1301 PLANTATION ISLAND DR S
Practice Address - Street 2:STE 105-B
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32080-3108
Practice Address - Country:US
Practice Address - Phone:904-826-1007
Practice Address - Fax:904-826-1073
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-08
Last Update Date:2012-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 1634442367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL98118OtherBCBS
FL000664500Medicaid
FL000664500Medicaid